Cardiovascular System and Exercise

Regular exercise makes the cardiovascular system more efficient at pumping

blood and delivering oxygen to the exercise muscles.[1, 2, 3, 8] Releases of
adrenaline and lactic acid into the blood result in an increase of the heart rate
(HR).
Basic definitions of terms are as follows:

VO2 equals cardiac output times oxygen uptake necessary to supply

oxygen to muscles.
The Fick equation is the basis for determination of VO2 (see image

Generally, the longer the duration of exercise, the greater the role the
cardiovascular system plays in metabolism and performance during the
exercise bout. An example would be the 100-meter sprint (little or no
cardiovascular involvement) versus a marathon (maximal cardiovascular
involvement).

General functions of the cardiovascular system

The cardiovascular system helps transport oxygen and nutrients to
tissues, transport carbon dioxide and other metabolites to the lungs and
kidneys, and distribute hormones throughout the body. The
cardiovascular system also assists with thermoregulation.

Cardiac cycle
The pumping of blood by the heart requires the following 2 mechanisms
to be efficient:

below).

Fick equation.

Exercises increase some of the different components of the cardiovascular

system, such as stroke volume (SV), cardiac output, systolic blood pressure
(BP), and mean arterial pressure. A greater percentage of the cardiac output
goes to the exercising muscles. At rest, muscles receive approximately 20% of
the total blood flow, but during exercise, the blood flow to muscles increases to
80-85%.
To meet the metabolic demands of skeletal muscle during exercise, 2 major
adjustments to blood flow must occur. First, cardiac output from the heart must
increase. Second, blood flow from inactive organs and tissues must be
redistributed to active skeletal muscle.

Alternate periods of relaxation and contraction of the atria and

ventricles
Coordinated opening and closing of the heart valves for
unidirectional flow of blood

The cardiac cycle is divided into 2 phases: ventricular diastole and

ventricular systole.

Ventricular diastole
o This phase begins with the opening of the atrioventricular
(AV) valves. The mitral valve (located between the left
atrium and left ventricle) opens when the left ventricular
pressure falls below the left atrial pressure, and the blood
from left atrium enters the left ventricle.
o Later, as the blood continues to flow into the left ventricle,
the pressure in both chambers tends to equalize.
o At the end of the diastole, left atrial contractions cause an
increase in left atrial pressure, thus again creating a

pressure gradient between the left atrium and ventricle and

forcing blood into the left ventricle.
Ventricular systole
o Ventricular systole begins with the contraction of the left
ventricle, which is caused by the spread of an action potential
over the left ventricle. The contraction of the left ventricle
causes an increase in the left ventricular pressure. When this
pressure is higher than the left atrial pressure, the mitral valve is
closed abruptly.
o The left ventricular pressure continues to rise after the mitral
valve is closed. When the left ventricular pressure rises above
the pressure in the aorta, the aortic valve opens. This period
between the closure of the mitral valve and the opening of the
aortic valve is called isovolumetric contraction phase.
o The blood ejects out of the left ventricle and into the aorta once
the aortic valve is opened. As the left ventricular contraction is
continued, 2 processes lead to a fall in the left ventricular
pressure. These include a decrease in the strength of the
ventricular contraction and a decrease in the volume of blood in
the ventricle.
o When the left ventricular pressure falls below the aortic
pressure, the aortic valve is closed. After the closure of the
aortic valve, the left ventricular pressure falls rapidly as the left
ventricle relaxes. When this pressure falls below the left atrial
pressure, the mitral valve opens and allows blood to enter left
ventricle. The period between the closure of the aortic valve
closure and the opening of the mitral valve is called
isovolumetric relaxation time.
o Right-sided heart chambers undergo the same phases
simultaneously.

Pressure changes during the cardiac cycle

Most of the work of the heart is completed when ventricular pressure exists.
The greater the ventricular pressure, the greater the workload of the heart.
Increases in BP dramatically increase the workload of the heart, and this is why
hypertension is so harmful to the heart.

Arterial BP is the pressure that is exerted against the walls of the vascular
system. BP is determined by cardiac output and peripheral resistance.
Arterial pressure can be estimated using a sphygmomanometer and a
stethoscope. The reference range for males is 120/80 mm Hg; the
reference range for females is 110/70 mm Hg.
The difference between systolic and diastolic pressure is called the pulse
pressure. The average pressure during a cardiac cycle is called the mean
arterial pressure (MAP). MAP determines the rate of blood flow through
the systemic circulation.

During rest, MAP = diastolic BP + (0.33 X pulse pressure). For

example, MAP = 80 + (0.33 X [120-80]), MAP = 93 mm Hg.
During exercise, MAP = diastolic BP + (0.50 X pulse pressure).
For example, MAP = 80 + (0.50 X [160-80]), MAP = 120 mm
Hg.

Coordinated control of the heart

The heart has the ability to generate its own electrical activity, which is
known as intrinsic rhythm. In the healthy heart, contraction is initiated in
the sinoatrial (SA) node, which is often called the heart's pacemaker. If
the SA node cannot set the rate, then other tissues in the heart are able to
generate an electrical potential and establish the HR.

Control of cardiac output (HR)

The parasympathetic nervous system and the sympathetic nervous system
affect a person's HR.

Parasympathetic nervous system: The vagus nerve originates in

the medulla and innervates the SA and AV nodes. The nerve
releases ACh as the neurotransmitter. The response is a decrease
in SA node and AV node activity, which causes a decrease in HR.
Sympathetic nervous system: The nerves arise from the spinal
cord and innervate the SA node and ventricular muscle mass. The
nerves release norepinephrine as the neurotransmitter. The

response is an increase in HR and a force of contraction of the

ventricles.

Control of sympathetic and parasympathetic activity

At rest, sympathetic and parasympathetic nervous stimulation are in balance.
During exercise, parasympathetic stimulation decreases and sympathetic
stimulation increases. Several factors can alter sympathetic nervous system
input.

The SV is inversely proportional to the aortic BP. During exercise,

the afterload is reduced, which allows for an increase in SV.
Strength of ventricular contraction: Epinephrine and
norepinephrine can increase the contractility of the heart by
increasing the calcium concentration within the cardiac muscle
fiber. Epinephrine and norepinephrine allow for greater calcium
entry through the calcium channels in cardiac muscle fiber
membranes. This allows for greater myosin and actin interaction
and an increase in force production.

Baroreceptors are groups of neurons located in the carotid arteries, the arch of
aorta, and the right atrium. These neurons sense changes in pressure in the
vascular system. An increase in BP results in an increase in parasympathetic
activity except during exercise, when the sympathetic activity overrides the
parasympathetic activity.

Control of cardiac output (venous return)

Chemoreceptors are groups of neurons located in the arch of the aorta and the
carotid arteries. These neurons sense changes in oxygen concentration. When
oxygen concentration in the blood is decreased, parasympathetic activity
decreases and sympathetic activity increases.

The muscle pump is the rhythmic contraction and relaxation of skeletal

muscle that compresses the veins and thus drains the skeletal muscle.
This causes greater blood flow back to the heart. The muscle pump is
very important during both resting and exercise conditions.

Temperature receptors are neurons located throughout the body. These neurons
are sensitive to changes in body temperature. As temperature increases,
sympathetic activity increases to cool the body and to reduce internal core
temperature.

During exercise, the respiratory pump helps increase venous return. The
pressure within the chest decreases and abdominal pressure increases
with inhalation, thus facilitating blood flow back to the heart. Because of
the increased respiratory rate and depth of breathing during exercise, this
is an effective way to increase venous return.

Control of cardiac output (SV)

SV is controlled by end-diastolic volume, average aortic BP, and the strength of
ventricular contraction.

End-diastolic volume: This is often referred to as the preload. If the

end-diastolic volume increases, the SV increases. With an increased
end-diastolic volume, a slight stretching of the cardiac muscle fibers
occurs, which increases the force of contraction
Average aortic BP: This is often referred to as the afterload. The BP in
the aorta represents a barrier to the blood being ejected from the heart.

Venoconstriction occurs as a response to sympathetic nervous system

stimulation. Sympathetic stimulation constricts the veins that drain
skeletal muscle. This causes greater blood to flow back to the heart.

Hemodynamics
The circulatory system is a closed-loop system, and flow through the
circulatory system is the result of pressure differences between the 2 ends
of the system, the left ventricle (90 mm Hg) and the right atrium
(approximately 0 mm Hg).
Systemic blood flow affects hemodynamics. The control of blood flow
during exercise is extremely important to ensure that blood and oxygen
are transported to the tissues that need them most. Blood flow to tissues

is dependent on the relationship between BP and the resistance provided by the

blood vessels.
Blood flow at rest is equal to the change in pressure divided by the resistance
of the vessels (ie, BF = P/R, where BF is blood flow, P is pressure, and R is
resistance). Blood flow during exercise is regulated by changing BP and
altering the peripheral resistance of the vessels.
The pressure change at rest in the cardiovascular system is 93 mm Hg, as
follows: Mean aortic pressure = 93 mm Hg, mean right atrial pressure = 0 mm
Hg, and driving pressure in the system = 93 mm Hg.
During exercise, BP increases so that blood flow through the body increases.
Blood flow is also increased during exercise by decreasing the resistance of the
vessels in the systemic circulation of active skeletal muscle. Resistance is
determined by the following formula:
Resistance = (length of tube X viscosity of blood)/radius4.
Changing the radius of the vessels has the most profound effect on blood flow.
Doubling the radius of a blood vessel decreases resistance by a factor of 16.
Decreasing the radius of a blood vessel by half increases resistance by a factor
of 16. The arterioles have the most control over blood flow in the systemic
circulation.

Changes in oxygen delivery to muscle during exercise

BP increases as exercise intensity increases, rising from approximately

120 mm Hg to approximately 200 mm Hg.
SV increases during exercise until 40% of VO2max (maximum oxygen
uptake level) is reached, rising from approximately 80 mL/beat to
approximately 120 mL/beat.
HR increases with intensity until VO2max is reached, rising from
approximately 70 beats per minute to approximately 200 beats per
minute.
Cardiac output increases with intensity until VO2max is reached, rising
from approximately 5 L/min to approximately 25-30 L/min.

The arterial-venous oxygen difference is the amount of oxygen extracted

from the blood as it passes through the capillary bed. This difference rises
from approximately 4 mL of oxygen per 100 mL of blood at rest to
approximately 18 mL of oxygen per 100 mL of blood during highintensity aerobic exercise.

Redistribution of blood flow during exercise

At rest, 15-20% of blood goes to skeletal muscle; during exercise, this
amount increases to 80-85%. The percentage of blood to the brain
decreases, but the absolute amount increases. The same percentage of
blood goes to cardiac muscle, but the absolute amount increases. Blood
flow to visceral tissues and inactive skeletal muscle reduces. In addition,
the cutaneous blood flow initially decreases, but it later increases during
the course of exercise.
The redistribution of the blood is brought about by several mechanisms.
During exercise, generalized vasodilatation occurs because of the
accumulation of vasodilatory metabolites. This leads to a decrease in the
peripheral resistance, which, in turn, elicits a strong increase in the
sympathetic activity through the activation of baroreceptors. The increase
in sympathetic activity leads to vasoconstriction in the visceral organs,
whereas the vasodilatation predominates in the blood vessels of the
muscles and the coronary circulation because of the local vasodilatory
metabolites. The cutaneous blood vessels initially respond to the
sympathetic activity by vasoconstriction. As the exercise continues,
temperature reflexes are activated and cause cutaneous vasodilatation to
dissipate the heat produced by the muscle activity, resulting in an increase
in the cutaneous blood flow.

Regulation of blood flow at the local level

The local blood flow is controlled by chemical factors, metabolites,
paracrines, physical factors such as heat or cold, stretch effects on
endothelial membrane, active hyperemia, and reactive hyperemia. The
paracrine regulation is mainly regulated by nitric oxide, histamine

release, and prostacyclin. Nitric oxide diffuses to smooth muscle and causes
vasodilation by reducing calcium entry into smooth muscle.

combination of arterial oxygen content, shunting of blood to muscles, and

the muscle extraction of oxygen.

Regulation of cardiovascular function

Training results in a more efficient heart and an increase in the maximum

SV. An increase in VO2 results in an ease in the stress of a given
workload. When maximum SV is increased, the heart can work more
efficiently at a given pulse rate. This lessens the necessity of an increased
pulse at a given workload. Resting pulse is lower, as is the pulse at any
given workload.

HR and blood flow are controlled by various centers in the brain. These centers
receive input from receptors located throughout the body. The centers work to
initiate the appropriate response from tissues and organs in the body.
Aerobic exercise requires oxygen to be present for the generation of energy
from fuels such as glucose or glycogen. Aerobic exercise results in no buildup
of lactic acid as a result of metabolism. This process is more efficient than
anaerobic metabolism. During normal rest and aerobic exercise, carbohydrates
and fats are used as fuels. A high degree of aerobic fitness requires a welladapted ability to take in, carry, and use oxygen. Laboratory measurements are
most accurate, but they are expensive. An individual's fitness level may be
estimated according to these measurements.
Anaerobic exercise produces lactic acid and is usually of short duration.
Anaerobic exercise is high intensity and has a greater inherent risk of injury.
Individuals who are unfit have a lower anaerobic threshold than athletes who
are aerobically trained. The well-trained athlete may be able to approach 80%
of the VO2max aerobically without lactate production.
The usual VO2 measurements are in L/min; however, if the size of the
individual needs to be accounted for, the measurements may be in mL/kg/min.
The values for the average person aged 20 years are 37-48 mL/kg/min. Male
athletes who are highly trained may approach measurements in the high 70s to
low 80s. Training enhances the ability of the body, in particular the muscle
cells, to better handle oxygen. Muscle must be able to use oxygen efficiently to
keep anaerobic metabolism at a given level of effort to a minimum.
Cardiac output is a major determinant of oxygen uptake. VO2max declines with
age as the maximum HR declines. This is one of the major factors causing the
approximately 7% decline with each decade of life after age 30 years. Muscle
training and use of oxygen at the end organ, muscle, is the second factor that
affects oxygen uptake. The arterial-venous oxygen difference comes about as a

One metabolic unit (MET) equals the VO2 at rest. The estimate of the
value of one MET is 3.5 mL of oxygen per kg/min. Conversion of VO2
measurements may be obtained by dividing the value of the VO2 in mL of
oxygen per kg/min by the value of one MET or 3.5. For example, a VO2
measurement of 35 mL of oxygen per kg/min is equivalent to an output
of 10 METs.

Cardiovascular changes with isometric exercise

Cardiovascular changes during isometric exercise differ from those
during dynamic exercise. Static exercise causes compression of the blood
vessels in the contracting muscles, leading to a reduction in the blood
flow in them. Therefore, total peripheral resistance, which normally falls
during dynamic exercise, does not fall and may, in fact, increase,
especially if several large groups of muscles are involved in the exercise.
The activation of the sympathetic system with exercise thus leads to an
increase in HR, cardiac output, and BP.
Because the total peripheral resistance does not decrease, the increase in
HR and cardiac output is less and an increase in the systolic, diastolic,
and mean arterial pressure is more compared with those seen with
dynamic exercise. Because BP is a major determinant of afterload, the
left ventricular wall stress, and thus the cardiac workload, is significantly
higher during static exercise compared with the cardiac workload
achieved during dynamic exercise.

Cardiac changes following training

In most cases, the SV plateaus at a VO2 of approximately 40-60% of the

maximum. This applies to both trained and untrained males and females. The
SV for untrained males may approach 100-120 mL/beat/min. For trained males,
this value is 150-170 mL/beat/min. For highly trained athletes, maximal SV
may reach or even exceed 200 mL/beat/min. The values for women are lower
than those for men. Maximal SV for untrained women is usually between 80
mL/beat/min, and for trained women, it is usually between 100 mL/beat/min.
These changes translate into an increase in the circulation blood volume and in
cardiac output, with a corresponding decrease in the resting HR and the resting
and exercise BP.
The heart undergoes certain morphologic changes in response to chronic
exercise, commonly seen via echocardiography. These morphologic changes
define what is commonly referred to as an "athletic heart." Athletic heart
syndrome is characterized by hypertrophy of the myocardium (ie, an increase
in the mass of the myocardium).
Although the hypertrophy in athlete's heart is morphologically similar to that
seen in patients with hypertension, several important differences exist. In
contrast to the hypertension-induced hypertrophy, the hypertrophy in the
athletic heart is noted in absence of any diastolic dysfunction, with a normal
isovolumetric relaxation time, with no decrease in the peak rate of left
ventricular filling, and with no decrease in the peak rate of left ventricular
cavity enlargement and wall thinning. Because the wall stress in the athlete's
heart is normal, sometimes the hypertrophy seems to be disproportionate to the
level of resting BP.
In addition, the rate of decline in the left ventricular hypertrophy and mass is
much more rapid when the training is stopped compared with the regression in
the same parameters in treated hypertension. On average, the decline in these
parameters is seen 3 weeks after stopping exercise, and these morphologic
changes can be seen on echocardiograms.
Sometimes, these morphologic changes are confused with the changes seen in
patients with hypertrophic cardiomyopathy (HCM). A few important
morphologic differences exist. In athletic heart syndrome, the hypertrophy is
usually symmetrical, as opposed to the asymmetrical hypertrophy in HCM.
Also, the left ventricular size is generally normal or increased, and the left

atrial size is normal, as opposed to a small left ventricular cavity with a

larger left atrial cavity size (usually >4.5 cm) in HCM. Despite these
differences, sometimes making a distinction between 2 conditions is a
challenge.

Summary
In summary, exercise is accomplished by alteration in the body response
to the physical stress (exercise physiology). These responses to exercise
include an increase in the HR, BP, SV, cardiac output, ventilation, and
VO2. The metabolism at the cellular level is also modulated to
accommodate the demands of exercise. These changes occur temporarily
during the exercise. Long-term changes also occur in the body
metabolism and function.
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2008;104(1):19-27. [Medline].

Background
Exercise prescription commonly refers to the specific plan of fitness-related
activities that are designed for a specified purpose, which is often developed by
a fitness or rehabilitation specialist for the client or patient. Due to the specific
and unique needs and interests of the client/patient, the goal of exercise

prescription should be successful integration of exercise principles and

behavioral techniques that motivates the participant to be compliant, thus
achieving their goals.[1, 2, 3, 4, 5, 6, 7]

Components of exercise prescription

An exercise prescription generally includes the following specific
recommendations:

Type of exercise or activity (eg, walking, swimming, cycling)

Specific workloads (eg, watts, walking speed)
Duration and frequency of the activity or exercise session
Intensity guidelines Target heart rate (THR) range and estimated
rate of perceived exertion (RPE)
Precautions regarding certain orthopedic (or other) concerns or
related comments

For an explanation of terms, see Glossary of Terms.

Overview
Substantial data are available regarding the benefits of physical activity.[1,
2, 3, 4, 5, 6, 7]
For primary preventative benefits, physical activity patterns
should begin in the early school years and continue throughout an
individual's life. Schools must specifically designate physical education
programs with aerobic activities for children at early ages. Programs
should include recreational sports (eg, running, dancing, swimming).
Support at home for an active lifestyle for children helps to promote
healthy physical activity patterns.
In the clinical setting, discuss physical activity and provide exercise
prescriptions for patients and their families. In some instances,
suggestions could be made about implementing physical activity
recommendations at the work site.
Consider intensity, duration, frequency, mode, and progression in all
types of physical activity programs. As children and adolescents become

adults and discontinue the athletic endeavors of school and college, primary
prevention must include a plan for a lifetime of appropriate physical activity.
Ideally, this activity should be performed for at least 30-60 minutes, 4-6 times
weekly or 30 minutes on most days of the week. The frequency, duration, and
intensity of activity should be individualized (exercise prescription) to personal
satisfaction, mode, and progression.
Subjects may use individual end points of exercise, such as breathlessness
and/or a fatigue level ranging from somewhat hard to hard on the Borg
perceived exertion scale (see Glossary of Terms, Borg rating of perceived
exertion [RPE]). Standardized charts that designate heart rates may help by
providing heart rate end points that can be measured immediately after
exercise, but these are not necessary. Exercise should include aerobic activities,
such as bicycling (stationary or routine), walk-jog protocols, swimming, and
other active recreational or leisure sports. Shoes and clothing should be
appropriate for extremes of heat, cold, and humidity.
Resistive exercises using free weights or standard equipment should be
performed 2-3 times per week. These exercises should include 8-10 exercise
sets that consist of 10-15 repetitions per set (including arms, shoulders, chest,
trunk, back, hips, and legs) and are performed at a moderate intensity. If free
weights are used, 15-30 lb is generally adequate or resistance that requires a
perceived effort that is relatively hard (ie, an RPE 15-16). Resistive exercises
tend to complement aerobic exercise in that some training effect is realized.[8]
However, as adults age, development of muscle tone and strengthening of body
musculature is more important.
The long-term effect of any physical activity program is affected by
compliance. In today's mobile society, an exercise plan must include activities
for business trips and vacations. Exercise facilities may not be convenient in
such settings, which may mean improvising. For example, a walk-jogger
should bring walking or running shoes and find a safe place to walk or run at a
pace that approximates the usual activity level. Many hotels or motels have
exercise facilities with a track or treadmill, exercise cycle, and weights,
enabling travelers or others away from their usual routine to maintain an
exercise program.

Physical activity measured in total time or kilocalories (kcal) or

kilojoules (kJ) per week is appropriate and may be achieved with various
combinations of scheduling, such as 10-15 minutes in the morning, at
noon, and/or an afternoon/evening session. Many persons may schedule
longer, less frequent periods of exercise. As intensity decreases,
frequency and duration should increase and vice versa. The dosage or
total energy (calorie) expenditure per week must be individualized
(exercise prescription).
Persons with influenza syndromes or respiratory illnesses should
decrease or stop exercise until they have recovered. If the recovery time
is greater than 2-3 weeks, activity should be resumed at a lower level to
compensate for the slight loss in training level. Maintenance of the
cardiovascular training effects of exercise has been shown to be more
related to the exercise intensity than to exercise frequency or duration. In
other words, if the intensity is maintained, even though the exercise
sessions are less frequent or shorter in duration, transient reductions in
conditioning from the decreased exercise appears to be minimized.
Various exercise testing measures of functional capacity should be used
in special populations but are not necessary for primary prevention.
Traditionally, many athletically inclined persons like to have periodic
oxygen-uptake (VO2) measurements to assess their level of training.
Physical activity levels are associated with long-term peak oxygen uptake
(VO2peak). Highly active individuals have higher VO2peak compared with
individuals who are inactive, and modification of activity levels from low
to high can lead to substantially higher VO2peak compared with continuing
to have low activity levels.[9]
Additionally, one study developed a nonexercise model of
cardiorespiratory fitness by assessing age, waist circumference, leisure
time physical activity, and resting heart rate. This model proved to be
fairly accurate in predicting VO2peak in a healthy population of both men
and women, and it may be a valid means of assessing cardiorespiratory
fitness in an outpatient setting.[10]
However, recent technologic advances have not only made
cardiopulmonary (CPX) or metabolic (CMET) testing more

commonplace among medical practices, but they have also become

increasingly popular as a part of a routine physical and stress test evaluation,
especially for individuals who are considered at high risk for cardiovascular
disease (eg, those with hypertension, shortness of breath, chest discomfort, or
abnormal blood lipid levels).
A lifestyle of physical activity from childhood throughout the adult years
fosters health and longevity. Even brisk walking as a physical activity/exercise
habit promotes health benefits. This is the simplest program for most
individuals and has clear benefits. This improved state of health is enhanced by
weight control, restricted intake of saturated fat and cholesterol, abstinence
from cigarette smoking, and control of high blood pressure and glucose
intolerance.
For patient education resources, visit the Public Health Center, as well as
Walking for Fitness and Strength Training.

Benefits of Exercise
Routine exercise improves tissue VO2 affects the following:

Improves insulin sensitivity

Improves glycemic control in persons with type 2 diabetes (and, hence,
decreases overall mortality)[11]
Decreases blood pressure
Decreases low-density lipoprotein and triglyceride levels
Increases high-density lipoprotein levels

Considerable data also support evidence that exercise may decrease the
prevalence of colon cancer and endometrial cancer. Exercise also helps with
osteoarthritis and obesity, as well as reportedly benefits persons with migraine
headaches and fibromyalgia.
Middle-aged men and women who work in physically demanding jobs or
perform moderate to strenuous recreational activities have fewer manifestations
of coronary artery disease than their less active peers. Meta-analysis studies of
clinical trials reveal that medically prescribed and supervised exercise can

reduce mortality rates for persons with coronary artery disease.[1, 7, 12, 13, 14,
15, 16]

The results from one study noted that moderate-to-vigorous physical

activity at least 3 times per week was associated with lower risk of
secondary cardiovascular disease (CVD) events in patients previously
diagnosed with CVD. Researchers suggest improvement of metabolic and
inflammatory risk markers as biological mechanisms.[17]
In a meta-analysis of 33 studies that included almost 200,000 participants
and cases, Kodama et al quantified the relationship between better
cardiorespiratory fitness and lower rates of coronary heart disease (CHD)
and CVD events, as well as deaths from all causes.[18] When
cardiorespiratory fitness was estimated as maximal aerobic capacity
(MAC) expressed in metabolic equivalent (MET) units, a MAC of 7.9
METs was associated with substantially lower rates of CHD/CVD events
and all-cause mortality.[18]
Furthermore, categorization of cardiorespiratory fitness as low (< 7.9
METs), intermediate (7.9-10.8 METs), or high (10.9 METs) yielded risk
ratios (RRs) for CHD/CVD in low-fitness participants of 1.47 compared
with intermediate-fitness participants and 1.56 compared with highfitness participants. The corresponding RRs for all-cause mortality in
low-fitness versus intermediate-fitness participants was1.40 and that of
low-fitness versus high-fitness participants was 1.70 (P < 0.001).[18]
Several studies suggest that relatively small amounts of physical activity
show considerable reductions in mortality and improved health outcomes
among participants when compared with sedentary control subjects.
These findings imply that a minimal activity (ie, exercising once per
week) may have positive health benefits even though fitness may not be
measurably improved. Some authors have suggested that a threshold of
physical activity may be necessary for maintaining optimal health and
that future investigations should involve control subjects who participate
in at least minimal activity levels rather than comparing exercise
treatment groups to control subjects who are completely sedentary.

In addition to the physical benefits of exercise, both short- and long-term

aerobic exercise training is associated with improvements in various indexes of
psychologic functioning. Cross-sectional studies reveal that compared with
sedentary individuals, active persons are more likely to be better adjusted, to
perform better on tests of cognitive functioning, to exhibit reduced
cardiovascular responses to stress, and to report fewer symptoms of anxiety and
depression.
In one report, persons who increased their activity levels from 1965-1974 were
at no greater risk for depression than those individuals who were active all
along; however, persons who were active and became inactive were 1.5 times
as likely to become depressed by 1983 compared with those who maintained an
active lifestyle. Longitudinal studies have also documented significant
improvement in psychologic functioning. Exercise training reduces depression
in healthy older men and in persons with cardiac disease or major depression.

occupational, recreational, sports-related) that are performed without the

specific purpose of fitness or health. Different types of exercise are as
follows:

Exercise also improves self-confidence and self-esteem, attenuates

cardiovascular and neurohumoral responses to mental stress, and reduces some
type A behaviors. Although exercise training generally has not been found to
improve cognitive performance, short bouts of exercise may have short-term
facilitative effects.
Despite the positive physical and mental health benefits of exercise, long-term
adherence to exercise programs remains problematic. Overall physical activity
levels decrease with aging, in minority populations, in females, in disabled
persons, and in those with chronic disease. Only an estimated 50% of all
persons who initiate an exercise program continue the habit for more than 6
months. The issue of nonadherence is particularly important because exercise is
only beneficial if it is maintained for extended periods. Thus, developing
strategies to improve exercise initiation and adherence, especially for persons
who are among the least active (eg, 75% of black women; less educated, obese,
elderly persons), is important.[19, 20, 21, 22, 23, 24]

General Guidelines
Resistance and repetitions

Different Types of Exercise

Exercise has been defined as an activity for the express purpose of improving
fitness or health. Physical activity includes all forms of activity (eg,

Aerobic (eg, walking, swimming)

Anaerobic (eg, sprinting)
Isotonic (eg, lifting weights)
Resistance training: This involves providing some form of
resistance to the contracting muscles to stimulate the body to
increase strength. Multiple types of equipment are used for
resistance training, including hand weights; cam machines;
pulleys; and hydraulic, elastic, rubber, fiberglass, and magnetic
equipment.
o Strength or resistance training is very important to
improve functionality and reduce the risk of injury. As
people age, the lean tissue (ie, muscle) declines more from
lack of use than from aging itself. Regularly performing
some type of resistance training is imperative.
o Because the demand on the heart is generally less during
strength training than while walking at a moderate pace,
resistance training is regarded as safe for patients with
many heart conditions. Patients should never strain or hold
their breath while attempting to lift something; straining
can adversely affect blood flow to the heart.

Resistance: The appropriate resistance may be provided by hand

weights, elastic resistance, calisthenics, or machines and should
be no more than what one can lift for approximately 15-20
repetitions. Perceived effort should only be moderate or
somewhat hard.
Repetition: A set is a group of repetitions, such as 2 or 3 sets of 15
repetitions. The number of sets depends on several factors,
including time constraints, motivation, and personal goals. One to

3 sets are adequate for strength development. Add 1 set per week,
increasing up to 3 sets.
Progress: Progression can be made as one finds that the weight being
used can be lifted more than 20-25 times. One should then increase the
resistance slightly (eg, add 1-5 lb) and resume the training. As one
reaches muscle fatigue, more stimulation of the muscle tissue results in
protein being added to the muscle groups. Significant strength changes
generally occur within 6 weeks.
Other: Stretching should also be part of the exercise plan.

Lifetime activities

Type of exercise (mode)

Intensity: This should range from low to moderate for healthy

individuals.
Duration: Continuous aerobic activity for 20-60 minutes is
recommended.
Frequency
o Individuals with a less than a 3-MET capacity should engage in
multiple short sessions each day.
o Individuals with a 3- to 5-MET capacity should engage in 1-2
sessions per day.
o Individuals with a greater than 5-MET capacity should engage
in 3-5 sessions per week.

Energy (caloric) expenditure

Per-minute calculation: To calculate kilocalories per minute (kcal/min),

multiply the METs times 3.5 times body weight in kilograms (kg) and
divide by 200 (ie, kcal/min = [METs 3.5 kg body weight]/200). For
example, the energy (caloric) expenditure of a 70-kg individual at a
prescribed 6-MET capacity with a weekly goal of 1000 per week is
calculated as (6 3.5 70 kg)/200, which equals 7.35 kcal/min (30.87
kJ/min). To convert kilocalories to kilojoules, note that 1 kcal = 4.2 kJ.
Per-week calculation: This determines the exercise duration per week.
Using the numbers from the example above, divide 1000 kcal (4200 kJ)
by 7.35 kcal/min (30.87 kJ/min), which equals 136 min/wk or
approximately 20-30 minutes, 6 d/wk.

Vary the type of activity. Pick an activity that is enjoyable. The

activity can be any type that uses most muscles, elevates the heart
rate, and may be sustained for 20 minutes or longer. For example,
one may find stationary cycling boring but enjoy playing tennis or
racquetball.
Vary the duration and intensity within the guidelines. Some days,
decrease the intensity of the activity but increase the duration. On
other days, warm up and then increase the intensity to the upper
range of the guidelines but decrease the duration.
Contract with a friend (buddy system) or participate in group
classes.
Use music for rhythm. If an activity is boring, either change it or
find another one that is enjoyable. For example, if one is
stationary cycling, videos that show outdoor scenery are
available. Also, new saddles are available that make cycling much
more comfortable.
Make exercising enjoyable by selecting at least 2 activities that
are enjoyable.
Conditioning may be realized from many activities if applied
correctly.
Walk daily, whether one has a dog or not.

Selecting the right physical activities

Select physical activities that are enjoyable, use most of the

muscles, are rhythmic, and may be sustained for several minutes
to an hour.
Plan to exercise every other day until more adequately adapted to
the activity.
Think of the frequency, intensity, time, and type (ie, FITT) plan.
o Frequency: This is how often per week one will perform
the exercise. Plan on most days of the week.
o Intensity: This is how hard one exercises. Moderate effort
is appropriate.

Time: This is the duration of each session. Start off with as little
as needed (10 min if necessary).
o Type: This is the choice of physical activity, which can include
recreational activities and domestic or occupational activities. A
short list of each follows:
Recreational activities
Participating in aerobic activity classes;
performing calisthenics, gymnastics, low-impact
aerobics, martial arts
Backpacking, climbing hills, stair climbing,
walking, hiking, orienteering, running
Playing badminton, baseball, basketball, catch
(eg, flying discs), cricket, handball, racquetball,
lacrosse, rugby, shuffleboard, table tennis, tennis,
volleyball, water polo
Body building, bowling, boxing, cycling,
dancing, fencing, gardening, golfing, horseback
riding, hunting, in-line skating, skating, rope
skipping, skiing, snow shoeing, weight lifting,
windsurfing
Canoeing, sailing, scuba diving, swimming,
fishing, participating in water activities
Domestic or occupational activities Cleaning windows,
doing housework, mowing, packing and unpacking,
plowing, sanding, sawing, sweeping, stocking shelves,
pushing a wheelbarrow, performing yard work, etc
Set goals, which may include those regarding health, improving
physical capacity or performance.
Motivation may be helpful for compliance. See the following tips:
o Join a class or facility, or contract with a friend (buddy system).
o Listen to one's body (eg, slowing down or skipping if tired or
ill). Start at the present level to prevent soreness.
o Exercise at the same time each day.
o Make sure to have good-quality nutrition.
o Make exercising a priority; scheduling a time benefits the
individual.
o Get advice if help is needed.
o

Exercise Prescription for Special Populations

Advanced age

Maximum ventilatory perfusion (VQ) drops 5-15% per decade in

individuals aged 20-80 years. A lifetime of dynamic exercise
maintains the individual's VQ at a level higher than that expected
for any given age. The rate of decline in VQ is directly related to
maintenance of the physical activity level, which emphasizes the
importance of physical activity.
Developing and maintaining aerobic endurance, joint flexibility,
and muscle strength is important in a comprehensive exercise
program, especially as people age. Elderly women and men show
comparable improvement in exercise training, and adherence to
training in elderly individuals is high.
Resistance training exercise alone has only a modest effect on risk
factors compared with aerobic endurance training, but resistance
training does aid carbohydrate metabolism through the
development or maintenance of muscle mass and effects on basal
metabolism. Furthermore, resistance training is recommended by
most health promotion organizations for its effects on
maintenance of strength, muscle mass, bone mineral density,
functional capacity, and prevention and/or rehabilitation of
musculoskeletal problems (eg, low back pain).
In elderly individuals, resistance training is both safe and
beneficial in improving flexibility and quality of life. Persons
with cardiovascular disease are usually asked to refrain from
heavy lifting and forceful isometric exercises, but moderateintensity dynamic strength training is safe and beneficial in
persons at low risk.

Pulmonary disease

Individuals with pulmonary disease should engage in low

workloads of short duration.
Patients should exercise in frequent intervals rather than a longer
duration and fewer intervals.

Supplemental oxygen is needed.

Diabetes

Exercise should be of short duration with a gradual progression to

longer durations, as tolerated.
Exercises include aquatic aerobics, swimming, walking, jogging, or
bicycling, among others.
Monitor blood sugar because hypoglycemia or hyperglycemia can occur
in diabetic persons during exercise.
o Before exercise: Consume a meal 1-3 hours before exercising,
administer insulin at least 1 hour before exercise, and, if the
blood glucose level is greater than 250 mg/dL, check urine for
ketones.
o During exercise: Supplement energy (caloric) intake every 30
minutes and maintain adequate fluid replacement.
o After exercise: Monitor the glucose level, increase energy
(caloric) intake for 12-24 hours following activity, and expect
postexercise hypoglycemia; thus, appropriately adjust insulin
dosing.

Obesity

Individuals who are morbidly obese should be cautious of orthopedic

stresses.
They may start with nonweight-bearing exercises (eg, swimming,
water aerobics, floor exercises).
These individuals should avoid high-impact aerobic activities.
Emphasize duration as tolerated and exercise frequency (sessions per
week).
Emphasize premeal exercise, especially exercise in the morning before
eating breakfast to mobilize fats (lipolysis).

Maternity

Research on exercise during pregnancy continues to demonstrate

marked benefits for the mother and fetus.[25, 26, 27, 28, 29] The type, intensity,

frequency, and duration of the exercise seem to be important

determinants of its beneficial effects.
Maternal benefits include improved cardiovascular function,
limited weight gain and fat retention, easier and less complicated
labor, quick recovery, and improved fitness. A small study
involving Hispanic women, the largest minority group in the
United States with the highest birth rates, evaluated physical
activity before and in early pregnancy. The results corroborated
data from previous studies that suggest physical activity in early
pregnancy decreases the risk of pregnancy-related hypertensive
disorders.[30]
Fetal benefits may include decreased growth of the fat organ,
improved stress tolerance, and advanced neurobehavioral
maturation.
Offspring are leaner at age 5 years and have a slightly better
neurodevelopmental outcome. Postpubertal effects are still
unknown.
In the absence of medical contraindications, women should be
encouraged to maintain their prepregnancy activity level. In
general, activity should be individualized (exercise prescription),
depending on previous activity levels
Available outcome data suggest that a healthy woman may begin
or maintain a regular exercise regimen during pregnancy, with
benefit and without adversely affecting the course and outcome of
the pregnancy. Data also suggest that the clear difference between
theoretic concern and observed outcome is best explained by the
hypothesis that the physiologic adaptations to exercise and to
pregnancy are complementary and fetoprotective.
Although an upper level of safe performance is not established,
otherwise healthy mothers-to-be appear to obtain the benefits of a
regular exercise regimen without undue risk to the embryo and
fetus. The exact regimen can be flexible and individualized
(exercise prescription), provided that both the exercise and the
pregnancy are monitored.

Osteoporosis

Exercise is an essential part of treatment for patients with osteoporosis.

Just as regular workouts build muscle, these activities also maintain and
may even increase bone strength. By strengthening the muscles and
bones and improving balance, exercise can reduce the risk of falls and
resulting fractures.
Exercise works well with medications that increase bone density and
strength.
Exercise, medication, and proper diet, including an absorbable source of
calcium, phosphorus, boron, and other bone-building minerals, are more
effective in combating osteoporosis than any one treatment alone.
Weight-bearing exercises and resistance training benefit bones and
muscles as well as help improve general health.
o Weight-bearing exercise
For most people who have osteoporosis, brisk walking is
ideal.
Walking can be performed anywhere, requires no special
equipment, and carries minimal risk of injury.
If walking is too difficult or painful, workouts on a
stationary exercise cycle are a good alternative.
o Resistance training
Lifting weights or using strength-training machines
strengthens bones, especially if one exercises all of the
major muscle groups in the legs, arms, and trunk.
A qualified trainer, exercise specialist, or therapist is
important for instructing and guiding resistance-training
programs.
Joining a gym or fitness facility is a good way to begin
because these facilities typically provide access to
trainers who can advise on proper techniques.
Strength training is a slow process, so it should be
started at a low level and should be gradually built up
over several months. For each exercise, select weights or
set the machine so the muscle being trained becomes
fatigued after 10-15 repetitions. As muscles strengthen,
gradually add more weight. The weight should not be
increased more than 10% per week because larger
increases can increase the risk of injury.

Tips for trouble-free exercise

Lift and lower weights slowly to maximize muscle strength and to

minimize the risk of injury.
Perform resistance workouts on any given muscle group every
second or third day. This gives your body a chance to recover.
Avoid exercise that puts excessive stress on the bones, such as
running or high-impact aerobics. Rowing is appropriate if proper
form is used and the rowing machine provides a way to maintain
continuous inertia with the use of a flywheel.
Stiffness is normal the morning after exercise. If pain continues
for most of the following day, joints become swollen, or a limp
develops, stop the program until comfortable again and reduce the
weight and number of repetitions by 25-50%. If bone, joint, or
muscle pain is severe, call the doctor.
If a particular area of the body feels sore right after exercise,
apply ice for 10-15 minutes. Wrap ice in a towel or plastic bag or
just hold a cold canned or bottled beverage on the spot.
Vary the routine to make it more interesting. For example, if the
strength-building program involves 12 separate exercises,
complete 6 in one session and the other 6 in the next session.

Exercise Prescription for Individuals With

Coronary Artery Disease
Physical inactivity is recognized as a risk factor for coronary artery
disease. Regular aerobic physical activity increases exercise capacity and
plays a role in both primary and secondary prevention of cardiovascular
disease.[1, 2, 3, 4, 5, 6, 7, 12, 13, 14, 15, 16] The known benefits of regular aerobic
exercise and recommendations for implementation of exercise programs
are discussed.
Exercise training increases cardiovascular functional capacity and
decreases myocardial oxygen demand at any level of physical activity in
apparently healthy persons and in most individuals with cardiovascular
disease. Regular physical activity is required to maintain these training

effects. Myocardial work can be affected by caffeine intake, and caffeine intake
has been shown to increase blood pressure response to exercise. The potential
risks of physical activity can be reduced by receiving a medical evaluation, risk
stratification, supervision, and education.
Exercise can help control blood lipid abnormalities, diabetes, and obesity. In
addition, aerobic exercise adds an independent blood pressurelowering effect
in certain hypertensive patient groups, with a decrease of 8-10 mm Hg in both
systolic and diastolic blood pressure measurements. A direct relationship exists
between physical inactivity and cardiovascular mortality, and physical
inactivity is an independent risk factor for the development of coronary artery
disease. A dose response relationship exists between the amount of exercise
performed (from approximately 700-2000 kcal/wk [2940-8400 kJ/wk] energy
expenditure) and all-cause mortality and cardiovascular disease mortality in
middle-aged and elderly populations.
The greatest potential for reduced mortality is in sedentary persons who
become moderately active. Most beneficial effects of physical activity on
cardiovascular disease mortality can be attained through moderate-intensity
activity (40-60% of maximal VQ, depending on the participant's age). The
activity can be accrued through formal training programs or leisure-time
physical activities. A large, 10-year, case-controlled study including men in the
Health Professionals Follow-up Study evaluated the effects of physical activity
on the risk of myocardial infarction. The results noted that men who
participated in vigorous-intensity activity for 3 h/wk reduced their risk of
myocardial infarction by 22%.[31]
Although most supporting data are based on studies in men, relatively recent
findings show similar results for women. Results of pooled studies reveal that
persons who modify their behavior after myocardial infarction to include
regular exercise have improved rates of survival.
Studies have revealed that intensive multiple interventions, such as smoking
cessation, blood lipid reduction, weight control, and physical activity,
significantly decreased the rate of progressionand, in some cases, lead to
regressionin the severity of atherosclerotic lesions in persons with coronary
disease.

In addition, limited data indicate that higher-intensity exercise, compared

with lower-intensity exercise, improves left ventricular ejection fractions
in persons with coronary artery disease. Current activity status (eg,
persons remaining physically active or having been sedentary and
becoming physically active) revealed the greatest decline in coronary
artery disease risk. Persons who remain sedentary have the highest risk
for cardiovascular disease mortality.
Exercise intensity should approximate 40-85% of VO2 reserve (VO2 R) or
HR reserve (HRR), as determined by an exercise test. If a test is not
performed initially, a reasonable estimate of 20-30 beats per minute
(bpm) above HR rest is generally appropriate until testing is performed.
Activities can be prescribed according to the work intensity at which the
training HR is achieved after 5-10 minutes at the same workload (steady
state). This may be expressed as watts on an ergometer, speed on a
treadmill, or METs. If an individual cannot assess intensity, HR counting
(manually or with a pulse meter or cardiotachometer) is especially useful.
HR counters are widely available and generally accurate for low- to
moderate-intensity exercise.
If an individual intends to walk on a level surface, activity can be
prescribed as the treadmill step rate that generates the desirable HR. The
step rate is the number of steps taken in 15 seconds while walking at the
desired speed on the treadmill. Step rate can be counted easily because it
requires less skill than counting HR. If this approach is used, caution
individuals to avoid hills. Walking in shopping malls or gymnasiums
allows individuals to avoid inclement weather and to exercise on a flat
surface. Exercise should be supervised for the first few sessions to ensure
that instructions are understood and the activity is well tolerated.
Individuals can also judge the intensity of exercise by the RPE, which
can be equated with the desired HR during laboratory exercise and
activities. The original scale is a 15-grade category scale that ranges from
6-20, with a verbal description at every odd number, beginning at 7 (very,
very light) and progressing to 19 (very, very hard).
RPE values should be rated as follows:

Less than 12 Perceived as fairly light (light intensity), 40-60% of

HRmax
From 12-13 Perceived as somewhat hard (moderate intensity), 6075% of HRmax
From 14-16 Perceived as hard (high intensity), 75-90% of HRmax

Activities can progress as tolerance is demonstrated. An appropriate initial

intensity of training is 60-75% of HRmax (moderate) or an RPE of 12-13.
However, many individuals may need to begin at 40-60% of HRmax (light).
After safe activity levels have been established, duration is increased in 5minute increments each week. Later, with increased strength and as the HR
response to exercise decreases with conditioning, intensities can be increased to
a frequency of 3-6 times per week. At this point, limited resistive exercises can
be added, which have proved both safe and effective in secondary prevention.

Exercise prescription in the presence of ischemia or arrhythmias

(moderate to high risk)
An exercise test and medical supervision are essential for this type of exercise
prescription. The manifestations of arrhythmias or ischemia that require such
precautions can vary but usually include the following:

Ventricular tachycardia (3-4 beats)

Any arrhythmia that is symptomatic or causes hemodynamic instability
Chest discomfort that is believed to be angina
Significant electrocardiograph (ECG) ST depression
Inappropriate blood pressure responses such as significant hypertension
or a decrease in systolic blood pressure of 20 mm Hg from baseline

Perform exercise testing in the usual fashion, but the conditioning work
intensity is derived from the HR associated with the abnormality. If the
exercise test continues to a high level of effort, the HR at 50-60% of maximum
can be used if it falls at least 10 bpm below the abnormal level. Otherwise, the
recommended peak training HR is 10 bpm less than that associated with the
abnormality. These individuals are recommended to have medically supervised
cardiac rehabilitation and reevaluation to restratify them to a lower risk. Repeat
exercise testing at least yearly.

As the population ages and more elderly persons survive coronary events,
increasing numbers need appropriate physical activity. Most of these
persons initially demonstrate benefits from supervised exercise for a brief
period. This is performed primarily to introduce the patient to exercise
(which the individual may not have performed before) and to evaluate the
patient for possible complications of exercise, such as arrhythmias,
evidence of heart failure, anginal chest pain, or abnormal ECG ST
segments. On the basis of the evaluation, the person can be categorized as
low risk or moderate to high risk, and appropriate cardiac rehabilitation
precautions can be taken.
Most individuals in secondary prevention can soon be restratified as low
risk and can implement their exercise prescription at home or in a
community program. In this setting, the previously mentioned primary
prevention guidelines also apply. The intensity may be much less, and the
frequency may be more, with appropriate changes in duration. Interval
exercise testing is recommended at least yearly, and coronary risk factor
modification should be aggressive.
In summary, implementation of physical activity strategies by physicians
for both primary and secondary prevention should consider the dosing
effect or expenditure of kilocalories or kilojoules over a unit of time
(usually a week). The guidelines above ideally should entail 5-6 hours of
various physical activities weekly if possible. The exercise routine must
be individualized (exercise prescription) and should include both aerobic
and resistance activities. The benefits of exercise are enhanced with good
to excellent compliance with exercise and appropriate lifestyle
modifications.

Postmyocardial infarction
As the safety of early ambulation was progressively demonstrated in
patients after suffering myocardial infarction, other benefits were
realized, such as the prevention of the deconditioning effects of bed rest,
decrease of anxiety and depression, and improved functional status at
discharge.

Early activity
o Walking is the recommended mode of activity unless the
individual can attend supervised classes where other activities
are provided. Begin limited walking and slowly continue, with a
gradual increase in duration until 5-10 minutes of continuous
movement has been achieved. Active but nonresistive range of
motion of the upper extremities is also well tolerated early if the
activities do not stress or impair healing of the sternal incision in
persons who have had coronary bypass surgery.
o The emphasis of exercise in the first 2 weeks after myocardial
infarction or coronary bypass surgery should be on offsetting the
effects of bed rest or former periods of inactivity. Begin to
increase activity when the individual's condition is stable, as
measured by ECG tracings, vital signs, and symptomatic
standards. Although the prescribed activity is usually well
tolerated and safe, certain precautions are recommended, such as
awareness of chest discomfort, faintness, and dyspnea.
o Supervise the initial activities and record symptoms, RPE, HR,
and blood pressure. When safety and tolerance are documented,
the activity can be performed without supervision.
Late activity
o A symptom-limited exercise test is often performed after the
individual's condition has stabilized (as early as 2-6 wk after the
coronary event). In secondary prevention, such testing is
essential in all patients before beginning a physical activity
program. If more studies (eg, echocardiography, angiography)
are not indicated, a regular conditioning program can be
initiated with a careful prescription of activity based on results
of the exercise test.
o For conditioning purposes, perform large muscle group
activities for at least 20-30 minutes (preceded by a warm-up and
followed by cool-down) at least 3-4 times per week. The
exercise prescription should be based on the exercise test results.
o Supervised group sessions are recommended initially to enhance
the exercise educational process, ensure that the participant is
tolerating the program, confirm progress, and provide medical
supervision in high-risk situations.

Unsupervised home programs are acceptable for persons

who are at low risk and who are motivated and understand
the basic principles of exercise training.

Additional Research and Future Issues

The body of knowledge on exercise is large, but data on exercise and its
effects on the cardiovascular system and long-term survival are still
relatively limited. The responsibility for conducting research lies with
government agencies, private health organizations, the insurance industry,
employers, universities, and medical schools.
Basic knowledge of the anatomic, biochemical, and physiologic changes
that result from various patterns of physical activity (short- and longterm, sustained and intermittent, isotonic and isometric, low and high
intensity) in persons of different ages is needed, as is a determination of
whether a certain minimum-intensity threshold of physical activity is
required for benefit.
The biomedical and economic impact of participation in exercise
programs on coronary artery disease, cerebrovascular and peripheral
vascular disease, heart failure, and hypertension should also be evaluated.
The psychosocial functioning of persons with coronary artery disease and
the potential value of exercise in enhancing the quality of life for cardiac
and other patients warrants further study. Future studies should include
adequate numbers of women, ethnic groups, and elderly persons to better
meet research objectives.
Furthermore, the presence and extent of coronary risk factors in disabled
and disadvantaged individuals and in minority groups must be identified
and better defined. Consequently, the effect of modifications (eg,
increases in physical activity on members of these groups) should be
explored. Large studies should also include a significant number of these
persons.
Research should be continued to establish the cost-effectiveness of
physical activity programs for the enhancement of cardiovascular health,

with a focus on the type of promotional strategies required for initiating and
maintaining physical activity (eg, insurance incentives, health personnel, public
policy, media materials) and the social context of such activity (eg, industry
and business, rural and urban settings, schools, churches, families). Research
should also involve issues such as how physical activity can prevent (or
decrease the duration of) the hospitalization of patients with chronic disease.
More information is also needed to identify societal, cultural, ethnic, and
personal factors that affect development or maintenance of lifelong patterns of
physical activity and incorporation of these into exercise promotion strategies.
Research on better and more effective physical activity interventions that
improve long-term compliance to a physically active lifestyle is urgently
needed. Innovative nontraditional methods of increasing physical activity in the
population must be developed, implemented, and evaluated.
In summary, future developments and studies should focus not only on the
benefits of physical activity, but also on exercise adherence strategies and the
methods used to facilitate dissemination of present and future knowledge to all
members of society.

based on the oxygen uptake reserve (VO2 R) rather than a direct

percentage of the VO2max.[32] Exercise intensities based on VO2 R are
approximately equal to the same percentage values for HRR; therefore,
the use of HRR in determining appropriate exercise intensities is suitable
in most cases. However, certain exceptions to using this approach may
include patients with poor chronotropic responses, dysautonomia,
pacemakers, or heart transplantation.
Target heart rate (THR) for exercise is generally recommended from
50% to 85% HRR (or VO2 R). For deconditioned individuals, 40-50%
HRR may be more appropriate for beginning exercise, whereas
physically active individuals may require higher intensities to achieve
improvements in their conditioning. As an illustration in determining
THR, the example below uses a resting HR (RHR) of 70 and a HRmax of
180 bpm.
The HRR is 180 70, or 110 bpm. Using an average intensity of 60-80%
HRR, the THR ranges are calculated (Karvonen approach) as follows:
THR = (HRR 60%) + RHR;

Glossary of Terms
Exercise intensity is generally expressed as a percentage of either HR or VO2.
By definition, VO2 is the oxygen uptake by an individual at rest or during
exertion, expressed commonly in milliliters of oxygen consumed per kilogram
body weight per minute (mL/kg/min)
Heart rate reserve (HRR) is defined as the maximal heart rate (HRmax)
observed during a symptom-limited exercise stress test minus the resting heart
rate (HR rest). A percentage of the HRR range is added to the HR rest to
determine a target heart rate (THR) range to be used during exercise. This
approach accounts for individual variability in the HR rest and better reflects
the peak exercise oxygen consumption (VO2max). VO2max reflects the highest rate
of oxygen consumption that one can achieve.
Oxygen uptake reserve (VO2 R) is the difference between resting and
maximal VO2. Previous guidelines suggest exercise prescriptions should be

THR = (110 0.60) + 70 = 136 bpm

to
(110 0.80) + 70 = 158 bpm
So, a THR range would be 136-158 bpm or a pulse count of 22-26 beats
per 10 seconds.
Metabolic equivalents (METs) are useful units when recommending
exercise. By definition, 1 MET is the amount of oxygen consumed at rest
or about 3.5 mL/kg/min. However, recent studies indicate that the
average resting MET level in subjects with coronary heart disease is 23%
to 36% lower than the 3.5 mL/kg/min standard value.[33] Nevertheless,
most people walking 2 mph require 2 METs, and 3 mph require 3-4
METs. Published MET tables describe many activities in terms of the
estimated MET requirements. For example, if an individual has a VO2max

of 34 mL/kg/min, the VO2 R is 34 minus the resting VO2 of 3.5 mL/kg/min

equals 30.5 mL/kg/min. Dividing this result by 3.5 yields 8.7 METs. Using 6080% VO2 R, the recommended range of exercise METs may be determined by
the following:

to

The respiratory exchange ratio (R or RER) or respiratory quotient

(RQ) is the ratio of the VO2 to the carbon dioxide produced in the body.
At rest, the RER reflects the substrate's use of fuel sources (eg,
carbohydrates, fats, proteins). The metabolism of fats or fatty acids yields
a ratio of 0.7; of carbohydrates, 1; and of protein, 0.84. During exercise,
the RER generally exceeds 1 because of the additional carbon dioxide
produced as a byproduct of the bicarbonate system and because of lactate
buffering.

(8.7 0.80) + 1.0 (resting) = 8 METs

Borg ratings of perceived exertion

When one consults a common MET table, an exercise intensity of 6.2-8.0

METs is equivalent to a slow walk-jog combination exercise, hiking with a
backpack, hill climbing, and numerous other moderately vigorous activities.

The RPE scale is used widely in exercise science and sports medicine to
monitor or prescribe levels of exercise intensity. The 95%-limits-ofagreement technique has been advocated as a better means of assessing
within-subject (trial-to-trial) agreement.

(8.7 0.60) + 1.0 (resting) = 6.2 METs

Exercise intensity may be customized to the individual (exercise prescription)

based upon their metabolic response to progressive exercise if the VO2max and
the anaerobic threshold (AT) or ventilatory threshold (VT) is determined.
By definition, the VT may be described as the level of oxygen consumption
(VO2) at which a significant increase in anaerobiosis occurs, as evidenced by
an increase in blood lactate levels and respiratory responses to the increasing
exercise workload. MET is a unit of energy or level of oxygen used at rest (1
MET = VO2 of 3.5 mL/kg/min).
Exertion below the VT can generally be sustained for long time periods;
whereas, above the VT, the individual can only tolerate a limited amount of
time such as several minutes. As a training principle, exercising at the VT may
be optimal due to considerable stimulation with a minimal lactate
accumulation. Many recreational as well as high-caliber endurance athletes
train above the VT but below the respiratory compensation (RC) point. The
RC may be described as the point when the CO2 production is increased in
relation to ventilation; typically when the individual no longer has voluntary
control over the ventilation (ie, the ventilation is driven by metabolic factors).
Maximal voluntary ventilation (MVV) is defined as the maximal amount of
ventilation per minute, generally determined by a 12-second hyperventilation
procedure to maximal ventilation capabilities.

The perception of exertion is a monitoring behavior that uses all sources

of information to govern actions that can benefit or preserve health and
partake of adaptive pursuits. How a person feels about exertion
moderates his or her response to exercise and effort. The perception of
what is happening in exercise, and its concomitant effect on physiologic
function, must be known to further understand the nature of an exercise
response. How a person feels modifies reactions to exercise stress and the
mechanisms that underlie them.
Exercise is never a purely mechanistic physiologic reaction. The
interpretation of the exercise experience governs the nature, quality, and
extent of the exercise response. To fully understand and accurately assess
the nature of an exercise behavior, measuring as many moderating
variables as possible is necessary.
Physiologic measures can be used to grade the strain for each individual,
but so can exertion estimates. In an exercise response, the underlying
determining mechanism may not be the pure physiologic parameter being
measured. Without knowledge of the psychologic moderator variables,
the physiologic measurement alone is misleading; its value as a predictor
variable is usually negligible. The particular circumstances in which the
physiologic measurement is taken may be more important for predicting

or analyzing a response than the variable itself. To exercise only according to

HR is dangerous. The aches and strain that are felt may be very important
indicators of the real degree of exertion. Rigid adherence to the objective
measures of physiology may cause interpretive and prescriptive errors of great
magnitude.
In many circumstances, the psychologic components of an exercise response
are more reliable and relevant than the physiologic measures. This has been
shown to be true in the assessment of long-term exercise strain for determining
the early symptoms of overtraining or maladaptation.
Borg's original intention was to construct a category scale from 6-20 in which
scale levels were roughly one tenth of the HR for equivalent scaled exercise
levels. A score of 6 (no exertion at all) should exhibit an HR somewhere in the
vicinity of 60 bpm for a young to middle-aged, mildly fit individual. This
correspondence is generally reserved for middle-aged people exercising at
moderate to high intensity levels. At best, this is a very rough estimation of the
relationship; individual variability is significant. Also, the relationship between
HR and RPE within an individual varies with different forms of activity. The
RPE is best reserved for intraindividual comparisons for a specific form of
exercise.
HRs are related linearly to the scale scores (r = 0.8-0.9). However, even with
this relationship one cannot conclude that HR is a cause of the perceived
exertion.
The perception of exertion integrates many more exercise factors than are
considered with singular or isolated physiologic variables. This integration is a
truer indication of an exercise response than is depicted by restricted variables
such as HRs, lactate measurements, or blood measurements. To understand a
certain RPE value, knowing (1) the age and other personal characteristics of the
individual, (2) what type of activity was performed, and (3) the environmental
conditions that existed at the time is important. The instructions for using the
scale are to "estimate how hard and strenuous you feel the work to be." The
perception should be general, rather than focusing on specific parts of the body
(eg, "tired arms"). The perception of exertion should include as many
contributory sensations as possible.

Once the verbal description is determined, the individual should choose

an exact number that corresponds to the verbal descriptor. When a subject
is unable to complete the highest workload, the rating should be of the
work at the time of the final interruption. With athletes, the major
problem with using RPE is their common tendency to underestimate the
exertion level. Practice in using the scale is necessary. If the various
categories can be aligned with other categories or levels of work
response, an accurate level of discrimination can be developed between
the categories. The RPE yields important additional data beyond those
available through isolated physiologic variables. In conscientious and
reliable individuals, its value exceeds that of singular parameters of
performance.
Instructions for use:
During the exercise you are to rate your perception of exertion. Use this
scale, where 6 means no exertion at all, and 20 means a totally maximum
effort. The 13 on the scale is a somewhat heavy exercise but capable of
being performed at steady state (ie, anaerobic threshold). When at a level
of 17, the effort level requires you to push yourself hard even though it is
possible to continue for some time. For many people, 19 is about as
strenuous as exercise becomes because they often reserve a small amount
of possible extra effort. Try to appraise the feeling of exertion as honestly
as possible. Do not underestimate or overestimate it. It is of no value to
underestimate the level to produce an impression of being brave or tough.
Your own feeling of effort and exertion is all that is of interest. Look at
the scale and wordings and decide on the word that best describes your
effort level and the number alternative associated with that description.
The Borg scale is as follows:

6 No exertion at all
7-8 Extremely light (very, very light)
9-10 Very light (A1 warm-up/recovery)
11 Light (A2 aerobic threshold)
12-13 Moderate (EN-1 anaerobic threshold)
14-15 Hard (EN-2 VO2max or 400-m swimming pace)

16-17 Very hard (AN-1 peak lactate or lactate tolerance, 200-m

swimming pace)
18-19 Extremely hard (very, very hard [AN-2 anaerobic power, 2550m swimming pace])
20 Maximum all-out effort, with absolutely nothing being held in
reserve

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Overview
History
Cardiovascular exercise stress testing in conjunction with an ECG has been
established as one of the focal points in the diagnosis and prognosis of
cardiovascular disease, specifically coronary artery disease (CAD).

Feil and Seigel first noticed the significance of cardiovascular exercise

stress testing in 1928; they reported ST and T changes following exercise
in 3 patients with chronic stable angina.[1] The following year, Master and
Oppenheimer introduced a standardized exercise protocol to assess
functional capacity and hemodynamic response.[2] Continued research
into causal mechanisms of ST displacement, refinement of exercise
protocols, and determination of diagnostic and prognostic exercise
variables in clinical patient subsets have continued to evolve since 1929.
After the establishment of coronary angiography as a diagnostic tool, the
limitation of exercise-induced ST-segment depression as a diagnostic
marker for obstructive CAD in patient populations with a low disease
prevalence became apparent.

Introduction
Exercise testing is a cardiovascular stress test using treadmill bicycle
exercise with ECG and blood pressure monitoring. Pharmacologic stress
testing, established after exercise testing, is a diagnostic procedure in
which cardiovascular stress induced by pharmacologic agents is
demonstrated in patients with decreased functional capacity or in patients
who cannot exercise. Pharmacologic stress testing is used in combination
with imaging modalities such as radionuclide imaging and
echocardiography. (For more information, see eMedicine article
Pharmacologic Stress Testing.)
Exercise stress testing, which is now widely available at a relatively low
cost, is currently used most frequently to estimate prognosis and
determine functional capacity, to assess the probability and extent of
coronary disease, and to assess the effects of therapy. Ancillary
techniques, such as metabolic gas analysis, radionuclide imaging (see
images below), and echocardiography, can provide further information
that may be needed in selected patients, such as those with moderate or
prior risk.

During strenuous exertion, sympathetic discharge is maximal and

parasympathetic stimulation is withdrawn, resulting in autoregulation
with generalized vasoconstriction, except in the vital organs (cerebral and
coronary circulations).

Normal radionuclide uptake (dipyridamole-

Venous and arterial norepinephrine release from sympathetic

postganglionic nerve endings is increased, and epinephrine levels are
increased at peak exertion, resulting in an increase in ventricular
contractility. As exercise progresses, skeletal muscle blood flow
increases; oxygen extraction increases as much as 3-fold; peripheral
resistance decreases; and systolic blood pressure (SBP), mean arterial
pressure, and pulse pressure usually increase. Diastolic blood pressure
(DBP) remains unchanged or may increase or decrease by approximately
10 mm Hg.
The pulmonary vascular bed can accommodate as much as a 6-fold
increase in cardiac output, with only modest increases in pulmonary
arterial pressure, pulmonary capillary wedge pressure, and right atrial
pressure; this is not a limiting determinant of peak exercise capacity in
healthy subjects.

Cardiolite).

Normal wall motion with radionuclide uptake.

Exercise physiology
The initiation of dynamic exercise results in increases in the ventricular heart
rate, stroke volume, and cardiac output due to vagal withdrawal and
sympathetic stimulation. Also, alveolar ventilation and venous return increase
as a result of sympathetic vasoconstriction. The overall hemodynamic response
depends on the amount of muscle mass involved, exercise efficiency,
conditioning, and exercise intensity.
In the initial phases of exercise in the upright position, cardiac output is
increased by an augmentation in stroke volume mediated through the use of the
Frank-Starling mechanism and heart rate. The increase in cardiac output in the
later phases of exercise is due primarily to an increase in ventricular rate.

The maximum heart rate and cardiac output are decreased in older
individuals, related in part to decreased beta-adrenergic responsiveness.
Maximum heart rate can be calculated by subtracting the patient's age (y)
from 220 (has a standard deviation of 10-12 beats per minute [bpm]). The
age-predicted maximum heart rate is a useful measurement for safety
reasons and as an estimate of the adequacy of the stress to evoke
inducible ischemia. A patient who reaches 80% of the age-predicted
maximum is considered to have a good test result, and an age-predicted
maximum of 90% or better is considered excellent.
In the postexercise phase, hemodynamics return to baseline within
minutes of discontinuing exercise. The return of vagal stimulation is an
important cardiac deceleration mechanism after exercise and is more
pronounced in well-trained athletes but blunted in patients with chronic
congestive heart failure. Intense physical work or important
cardiorespiratory impairment may interfere with achievement of a steady
state, and an oxygen deficit occurs during exercise. The oxygen debt is

the total oxygen uptake in excess of the resting oxygen uptake during the
recovery period.

Diagnosis and prognosis of cardiovascular disease, specifically

coronary artery disease (CAD)

Clinical guidelines

Contraindications

American College of Cardiology (ACC)/American Heart Association (AHA)

guidelines for exercise stress testing were initially formed in 1997 to create
recommendations regarding the appropriate use of testing in the diagnosis,
prognosis, and treatment of patients with known or probable cardiovascular
disease. These guidelines were revised in 2002.[3]

The following contraindications are from the AHA/ACC guidelines

published in 1997.

The new recommendations that appear in this update are based on significance
of the supporting data. The weight of evidence was ranked highest (A) if the
data were based on multiple randomized clinical trials that involved large
numbers of patients. An intermediate rank (B) indicates that the data were
derived from a limited number of randomized trials that involved small
numbers of patients or from careful analyses of nonrandomized studies or
observational registries. If expert consensus was the primary basis for the
recommendation, a lower rank (C) is given.
Exercise testing is a well-established procedure that has been in widespread
clinical use for decades, and, although it is generally a safe procedure, both
myocardial infarction and death have been reported and can be expected to
occur at a rate of 1 incident per 2500 tests. Therefore, use good clinical
judgment when deciding which patients should undergo exercise testing.
When considering the use of exercise testing in individual patients, factors that
are important in establishing good clinical outcomes include the quality,
expertise, and experience of the professional and technical staff performing and
interpreting the study to reduce observer error; the sensitivity, specificity, and
accuracy of the technique to establish limitations of this procedure; and the cost
and accuracy of the technique as compared with more expensive imaging
procedures to establish the risk-to-benefit ratio, to determine the effect of
positive or negative results on clinical decision making, and, lastly, to weigh
the potential psychological benefits of patient reassurance.

Indications

Absolute contraindications
o Acute myocardial infarction (within 2 d)
o Unstable angina not previously stabilized by medical
therapy: Appropriate timing of tests depends on the level
of risk of unstable angina as defined by the Agency for
Health Care Policy and Research Unstable Angina
Guidelines.
o Uncontrolled cardiac arrhythmias causing symptoms or
hemodynamic compromise
o Symptomatic severe aortic stenosis
o Uncontrolled symptomatic heart failure
o Acute pulmonary embolus or pulmonary infarction
o Acute myocarditis or pericarditis
o Acute aortic dissection
Relative contraindications: Relative contraindications can be
superseded if the benefits of exercise outweigh the risks.
o Left main coronary stenosis
o Moderate stenotic valvular heart disease
o Electrolyte abnormalities
o Severe arterial hypertension: In the absence of definite
evidence, the committee suggests an SBP of greater than
200 mm Hg and/or a DBP of greater than 110 mm Hg.
o Tachyarrhythmias or bradyarrhythmias
o Hypertrophic cardiomyopathy and any other forms of
outflow tract obstruction
o Mental or physical impairment leading to an inability to
exercise adequately
o High-degree atrioventricular (AV) block

The vast majority of treadmill exercise testing is performed on adults with

symptoms of known or probable ischemic heart disease. Candidates for
exercise stress testing may have stable symptoms of chest pain, may be
stabilized by medical therapy following symptoms of unstable chest pain, or
may have already had a myocardial infarction or a vascularization procedure.
The clinical suggestion of CAD based on patient history findings, ECG
tracings, and symptoms of chest pain must be established and used as a guide
to determine if treadmill exercise testing may be useful according to the Bayes
theorem, which states that the diagnostic power of exercise stress testing is
maximal when the pretest probability of CAD is intermediate (30-70%) based
on age, sex, and the nature of the chest pain. When the diagnosis of CAD is
certain, based on age, sex, description of chest pain, and history of prior
myocardial infarction, a clinical need may arise for risk or prognostic
assessment to reach a decision regarding possible coronary angiography or
revascularization to guide further medical management.

Inferior wall myocardial infarct and a

Myocardial infarction (see images below) is a common first presentation of

ischemic heart disease. This subset of patients also may require prognostic
and/or risk or assessment.
fixed defect.
Motion abnormalities in the inferior wall
consistent with an inferior wall myocardial infarction.

Infero-basal fixed defect and lateral wall

Class I: These are conditions for which evidence and/or general

agreement exists that a given procedure or treatment is useful and
effective.
Class II: These are conditions for which conflicting evidence
and/or a divergence of opinion exists concerning the usefulness or
efficacy of a procedure or treatment.
o Class IIa: The weight of evidence/opinion is in favor of
usefulness/efficacy.
o Class IIb: The usefulness/efficacy is less well established
by evidence/opinion.
Class III: These are conditions for which evidence and/or general
agreement exists that the procedure/treatment is not
useful/effective and, in some cases, may be harmful.

Anesthesia

No anesthesia is required for this examination.

Technique
ischemia.

Wall motion abnormalities in the infero-basal region.

Treadmill protocol

In the original guidelines, the committee did not rank the available scientific
evidence as A, B, or C, as described above. The level of evidence is considered
in the new recommendations that appear in this update. The weight of evidence
was ranked highest (A) if the data were based on multiple randomized clinical
trials that involved large numbers of patients. An intermediate rank (B)
indicates that the data were derived from a limited number of randomized trials
that involved small numbers of patients or from careful analyses of
nonrandomized studies or observational registries. If expert consensus was the
primary basis for the recommendation, a lower rank (C) is given. When few or
no data exist, this is noted in the text, and the recommendations are based on
the expert consensus of the committee.

Report exercise capacity in estimated metabolic equivalents (METs) of

exercise. A MET refers to the resting volume oxygen consumption per
minute (VO2) for a 70-kg, 40-year-old man. One MET is equivalent to
3.5 mL/min/kg of body weight. An example is the standard Bruce
protocol, which starts at 1.7 mph and 10% grade (5 METs) with larger
increments between stages than other protocols, such as the Naughton,
Weber, and Asymptomatic Cardiac Ischemia Pilot (ACIP) study, which
start at less than 2 METs at 2 mph and increase in 1- to 1.5-MET
increments between stages. The Bruce protocol has 3-minute periods to
allow achievement of a steady state before workload is increased.

The ACC/AHA classifications I, II, and III are used to summarize indications
for exercise stress testing and are listed as follows:

Stage 1 is 1.7 mph at 10% grade (5 METs). Stage 2 is 2.5 mph at 12%
grade (7 METs). Stage 3 is 3.4 mph at 14% grade (9 METs).

The modified Bruce protocol has two 3-minute warmup stages at 1.7 mph and
0% grade and 1.7 mph and 5% grade, and it is most often used in older
individuals or those whose exercise capacity is limited by cardiac disease.

Other exercise protocols include bicycle and arm ergometry, both of which are
used less often than treadmill stress testing in North America. The bicycle
ergometer has the advantage of requiring less space than a treadmill. It is
quieter, permits sensitive precordial measurements without much motion
artifact, and is generally safer because the risk of falling from the machine is
lower.

o
o

o
o

Indications for terminating exercise testing

According to the ACC/AHA guidelines, the following are indications for
termination of exercise testing:

Absolute indications for termination of exercise testing

o Drop in SBP of greater than 10 mm Hg from baseline blood
pressure, despite an increase in workload, when accompanied by
other evidence of ischemia
o Moderate-to-severe angina
o Increasing nervous system symptoms (eg, ataxia, dizziness,
near-syncope)
o Signs of poor perfusion (cyanosis or pallor)
o Technical difficulties in monitoring ECG tracings or SBP
o Subject's desire to stop
o Sustained ventricular tachycardia
o ST elevation (1 mm) in leads without diagnostic Q waves (other
than V1 or aVR)
Relative indications for terminating exercise testing
o Drop in SBP greater than or equal to 10 mm Hg from baseline
blood pressure, despite an increase in workload, in the absence
of other evidence of ischemia
o ST or QRS changes such as excessive ST depression (more than
2 mm of horizontal or down-sloping ST-segment depression) or
marked axis shift

Arrhythmias other than sustained ventricular tachycardia,

including multifocal premature ventricular contractions
(PVCs), triplets of PVCs, supraventricular tachycardia,
heart block, or bradyarrhythmias
Fatigue, shortness of breath, wheezing, leg cramps, or
claudication
Development of bundle branch block or intraventricular
conduction delay that cannot be distinguished from
ventricular tachycardia
Increasing chest pain
Hypertensive response (SBP of 250 mm Hg and/or DBP
greater than 115 mm Hg)

Interpretation
Interpretation should include exercise capacity and clinical,
hemodynamic, and ECG response. The occurrence of ischemic chest pain
consistent with angina is important, particularly if it forces termination of
the test. The classic criteria for visual interpretation of positive stress test
findings are J-point (defined as the junction of the point of onset of the
ST-T wave and normally at or near the isoelectric baseline of the ECG)
and ST80 (defined as the point that is 80 ms from the J point) depression
of 0.1 mV (1 mm) or more and/or an ST-segment slope within the range
of 1 mV/s in 3 consecutive beats.
Noncoronary causes of ST-segment depression include the following:

Severe hypertension
Severe aortic stenosis
Cardiomyopathy
Anemia
Hypokalemia
Severe hypoxia
Digitalis
Sudden excessive exercise
Glucose load
Left ventricular hypertrophy

Hyperventilation
Mitral valve prolapse
Intraventricular conduction delay
Preexcitation syndrome (Wolff-Parkinson-White [WPW] syndrome)
Severe volume overload (aortic, mitral regurgitation)
Supraventricular tachyarrhythmias

Complications
Exercise testing is a well-established procedure that has been in widespread
clinical use for decades, and, although it is generally a safe procedure, both
myocardial infarction and death have been reported and can be expected to
occur at a rate of 1 incident per 2500 tests. Therefore, use good clinical
judgment when deciding which patients should undergo exercise testing.

Diagnosis, Risk Assessment, and Special

Populations
Diagnosis of obstructive coronary artery disease
When using exercise testing in patients thought to have coronary artery disease
(CAD), classify these patients to properly assess the risks versus benefits. The
ACC/AHA guidelines outline these as follows:

Class I: These are adult patients (including those with complete right
bundle branch block or less than 1 mm of resting ST depression [at the
ST80 point]) with an intermediate pretest probability of CAD based on
sex, age, and symptoms (specific exceptions are noted under classes II
and III).
Class IIa: These are patients with vasospastic angina.
Class IIb
o Patients with a high pretest probability of CAD based on age,
symptoms, and sex
o Patients with a low pretest probability of CAD based on age,
symptoms, and sex

Patients with less than 1 mm of baseline ST depression

who are taking digoxin
o Patients with ECG criteria for left ventricular hypertrophy
(LVH) and less than 1 mm of baseline ST depression
Class III
o Patients with the following baseline ECG abnormalities:
preexcitation syndrome (WPW syndrome), electronically
paced ventricular rhythm, greater than 1 mm of resting ST
depression, or complete left bundle branch block
o Patients with a documented myocardial infarction or prior
coronary angiography findings demonstrating significant
disease who have an established diagnosis of CAD:
Testing can help determine ischemia and risk (see Risk
Assessment and Prognosis of Symptomatic Patients or
Those With CAD and Exercise Testing After Myocardial
Infarction).
o

Rationale
Exercise stress testing can be useful in establishing the diagnosis of
significant obstructive CAD when the diagnosis is in question, and,
although other clinical findings such as dyspnea upon exertion, resting
ECG tracing abnormalities, or multiple risk factors for atherosclerosis
may suggest the possibility of CAD, the most important clinical finding
is a history of chest discomfort or pain. Myocardial ischemia is the most
important cause of chest discomfort or pain and is most commonly a
consequence of underlying CAD.
Pretest probability
The clinician's estimation of the pretest probability of CAD is primarily
based on the patient's history. The most predictive parameters are the
description of chest pain, sex, and age. The pretest probability of CAD
based on these parameters is applied in the Bayes theorem, and,
according to this theorem, the diagnostic power of exercise testing results
is maximal when the pretest probability of CAD is intermediate (3070%).

The usefulness of exercise testing for the diagnosis of CAD is expressed most
commonly by sensitivity and specificity. Sensitivity varies from 61-73% as
reported by various analysts, and specificity varies from 59-81% depending on
the study or article referenced. Results of correlative studies have been divided
concerning the use exercise stress testing in patients with 50% or 70% luminal
diameter occlusion.
A meta-analysis of 58 consecutively published reports involving 11,691
patients without prior myocardial infarction who underwent coronary
angiography and exercise testing revealed a wide variability in sensitivity and
specificity. Mean sensitivity was 67%; mean specificity was 72%. In the 3
studies in which workup bias was avoided by having the patients agree to
undergo both coronary angiography and exercise testing, the approximate
sensitivity and specificity of 1 mm of horizontal or down-sloping ST
depression for diagnosing CAD were 50% and 90%, respectively. The true
diagnostic value of the exercise ECG findings apparently lies in their relatively
high specificity. The wide variability in test performance apparent from this
meta-analysis demonstrates the importance of using proper methods for testing
and analysis. Consider up-sloping ST depression as a borderline positive test
result or a result possibly warranting further diagnostic testing.
The standard exercise test remains the first option in the evaluation of possible
CAD in patients with an indeterminate pretest probability, although resting ST
depression of less than 1 mm somewhat lowers specificity. LVH with less than
1 mm of ST depression (at the ST80 point) and the use of digoxin with less
than 1 mm of depression also lower specificity, but the standard exercise test
remains a reasonable option in such patients.
In contrast, other baseline ECG abnormalities, such as preexcitation,
ventricular pacing, greater than 1 mm of ST depression (at the ST80 point) at
rest, and complete left bundle branch block, greatly affect the diagnostic
performance of the exercise test results. Imaging modalities are preferred in the
subset of patients with other baseline ECG abnormalities. While computer
processing of the exercise ECG can be helpful, it can result in a false-positive
depiction of ST depression. To avoid this problem, the ordering clinician
should always be provided with ECG recordings of the raw unprocessed ECG
data for comparison with any averages the exercise test monitor generates.

New pretest probability considerations

In the new guideline review, other clinical scores have been developed
that could better predict pretest probability of CAD. These mathematical
equations, or scores, developed from multivariable analysis of clinical
and exercise test variables provide superior discrimination over the ST
segment response alone in the diagnosis of CAD. Such scores can
provide probabilities of CAD that are more accurate than ST
measurements alone. Detailed nomograms are available that incorporate
the effects of a history of prior infarction, electrocardiographic Q waves,
electrocardiographic ST- and T-wave changes, diabetes, smoking, and
hypercholesterolemia. History and electrocardiographic evidence of prior
infarction dramatically affect pretest probability. The Duke treadmill
prognostic score has been shown to be better than ST depression alone
for diagnosing angiographic coronary disease.
The variability of the reported diagnostic accuracy of the exercise ECG
has been studied by meta-analysis and, despite workup bias, this analysis
provides the best description of the diagnostic accuracy of the exercise
stress test.
Confounders of exercise stress testing
Confounders of exercise stress testing include the following:

Digoxin
Resting ST depression
Left ventricular hypertrophy
Atrial repolarization
o Atrial repolarization waves are opposite in direction to P
waves and may extend into the ST segment and T wave.
Exaggerated atrial repolarization waves during exercise
can cause downsloping ST depression in the absence of
ischemia.
o Patients with false-positive exercise test results based on
this finding have a high peak exercise heart rate, an

absence of exercise-induced chest pain, and markedly

downsloping PR segments in the inferior leads.
Left bundle branch block

Right-sided chest leads

In a new approach, Michaelides et al examined 245 patients who underwent
exercise testing with standard 12 leads, right ventricular leads, and thallium201 scintigraphy. They found sensitivities of 66%, 92%, and 93% and
specificities of 88%, 88%, and 82%, respectively, for the detection of CAD
based on angiography, ie, results comparable with those of perfusion scanning
when right-sided leads were added. However, this study was performed in a
population with an abnormally high prevalence of coronary disease, and the
committee would not recommend clinical use of right-sided chest leads until
these results are confirmed by others.[4]
STheart rate adjustment
Several methods of heart rate adjustment have been proposed to increase the
diagnostic accuracy of the exercise ECG. The maximal slope of the ST segment
relative to heart rate is derived either manually or by computer. A second
technique, termed the STheart rate (ST/HR) index, divides the difference
between ST depression at peak exercise by the exercise-induced increase in
heart rate. ST/HR adjustment has been the subject of several reviews since the
last publication of these guidelines.
The major articles that used this approach for diagnostic testing include
Morise's[5] report of 1358 individuals undergoing exercise testing (only 152
with catheterization data) and the report by Okin et al[6] considering heart rate
reserve (238 controls and 337 patients with coronary disease). Viik et al[7]
considered the maximum value of the ST/HR hysteresis over a different
number of leads for the detection of CAD. The study population consisted of
127 patients with coronary disease and 220 patients with a low likelihood of
the disease referred for an exercise test.

rates and sick patients have low heart rates. Because this leads to a lower
ST/HR index in those without disease and a higher index in sicker
patients, the enrollment of relatively healthy patients in these studies
presents a limited challenge to the ST/HR index. Likewise, the Morise
study had a small number of patients who underwent angiography. The
only study with neither of these limitations was QUEXTA. This large,
multicenter study followed a protocol to reduce workup bias and was
analyzed by independent statisticians. The ST/HR slope or index was not
found to be more accurate than simple measurement of the ST segment.
Although some studies in asymptomatic (and therefore very low
likelihood) individuals have demonstrated additional prognostic value
with the ST/HR adjustment, these data are not directly applicable to the
issue of diagnosis in symptomatic patients. Nevertheless, one could take
the perspective that the ST/HR approach in symptomatic patients has at
least equivalent accuracy to the standard approach. Although not yet
validated, the ST/HR approach could prove useful in some situations,
such as in rendering a judgment concerning certain borderline or
equivocal ST responses (eg, ST-segment depression associated with a
very high exercise heart rate). Although the initial reports were
promising, neither meta-analysis nor a subsequent study found
convincing evidence of benefit. In interpretation of exercise tests,
exercise capacity is more important to consider than exercise heart rate.
Computer processing
Although computer processing of the exercise ECG can be helpful, it can
result in a false-positive indication of ST depression. To avoid this
problem, the ordering clinician should always be provided with ECG
recordings of the raw, unprocessed ECG data for comparison with any
averages the exercise test monitor generates.

Neither the Okin et al study nor the Viik et al study considered consecutive
patients with chest pain, and both had limited challenge. Limited challenge
favors the ST/HR index because healthy patients have relatively high heart

Preferably, averages should always be contiguously preceded by

the raw ECG data.
The degree of filtering and preprocessing should always be
presented along with the ECG recordings and should be compared
with the AHA recommendations (0-100 Hz with notched power

line frequency filters). Preferably, the AHA standards should be the

default setting.
All averages should be carefully labeled and explained, particularly
those that simulate raw data. Simulation of raw data with averaged data
should be avoided.
Obvious breaks should be inserted between averaged ECG complexes.
Averages should be marked to indicate the PR isoelectric line and the
ST measurement points.

None of the computerized scores or measurements has been validated

sufficiently to recommend their widespread use. At least one study in which
these shortcomings have been addressed showed that computerized
measurements are comparable with visual measurements and that they can
provide excellent test characteristics when combined with scores.

Risk assessment and prognosis of symptomatic patients or those

with CAD
For proper evaluation, risk assessment, and prognosis in symptomatic patients
or those with CAD, the ACC/AHA guidelines are as follows:

Class I
Patients undergoing initial evaluation with possible or known
CAD, including those with complete right bundle branch block
or less than 1 mm of resting ST depression (Specific exceptions
are noted below in class IIb.)
o Patients with possible or known CAD previously evaluated now
presenting with significant change in clinical status
o Low-risk patients with unstable angina, 8-12 hours after
presentation who have been free of active ischemic or heart
failure symptoms (level of evidence: B)
o Intermediate-risk patients with unstable angina 2-3 days after
presentation who have been free of active ischemic or heart
failure symptoms (level of evidence: B)
Class IIa - Intermediate-risk patients with unstable angina who have
normal initial cardiac markers, a repeat ECG without significant
change, normal cardiac markers 6-12 hours after the onset of symptoms,
o

and no other evidence of ischemia during observation (level of

evidence: B)
Class IIb
o Patients with the following resting ECG abnormalities:
preexcitation syndrome (WPW syndrome), electronically
paced ventricular rhythm, resting ST depression greater
than 1 mm, complete left bundle branch block, or any
interventricular conduction defect with a QRS duration
greater than 120 milliseconds
o Patients with a stable clinical course who undergo periodic
monitoring to guide treatment
Class III
o Patients with severe comorbidity likely to limit life
expectancy, candidacy for revascularization, or both
o High-risk patients with unstable angina (level of evidence:
C)

Patients with possible or known CAD and new or changing symptoms

that suggest ischemia should generally undergo exercise testing (only if
cardiac catheterization is not indicated) to assess their risk for future
cardiac events.
Documentation of exercise or stress-induced ischemia is desirable for
most patients undergoing evaluation for revascularization, according to
the ACC/AHA guidelines for percutaneous transluminal coronary
angioplasty (PTCA) and coronary artery bypass graft (CABG).
When determining the initial stress test modality, evaluate the patient's
resting ECG findings, physical ability to exercise, and local expertise and
technologies. For risk assessment, the exercise test should be the standard
initial mode of stress testing used in patients at the provider's institution
who have normal ECG tracings and who are not taking digoxin.
In patients who are unable to exercise because of physical limitations (eg,
arthritis, amputations, severe peripheral vascular disease, severe chronic

obstructive pulmonary disease [COPD], general debility), pharmacological

stress testing in combination with imaging is recommended.
Exercise testing may be useful for prognostic assessment of patients taking
digoxin or patients with abnormal resting ECG findings, but its usefulness is
less well established in this setting. Patients with preexcitation, ventricularpaced rhythm, widespread ST depression (1 mm or more), or complete left
bundle branch block (an intraventricular conduction defect with a QRS
duration longer than 120 ms) should usually be tested with an imaging
modality. Exercise testing may provide prognostic information (particularly
exercise capacity) in patients with nondiagnostic ECG changes, but it cannot be
used to identify ischemia.
One of the strongest and most consistent prognostic markers identified in
exercise testing is maximum exercise capacity, which is at least partly
influenced by the extent of resting left ventricular dysfunction and the amount
of increased left ventricular dysfunction induced by exercise.
When interpreting an exercise test result, considering exercise capacity is very
important. This may be achieved with one of several markers of exercise
capacity, including maximal exercise duration, maximal MET level achieved,
maximum workload achieved, or maximum heart rate and heart rateblood
pressure product.
A second group of prognostic markers identified from the exercise test relates
to exercise-induced ischemia and includes exercise-induced ST deviation
(elevation and depression) and exercise-induced angina.
The Duke treadmill score incorporates both groups of prognostic markers
(exercise capacity and exercise-induced ischemia). This score was originally
developed using data from 2842 inpatients with known or possible CAD who
underwent exercise testing before diagnostic angiography and had no prior
revascularization or recent myocardial infarction. The score applies equally
well in males and females but has not been evaluated extensively in elderly
patients.
Risk assessment also may be appropriate in certain patients with unstable
angina. Guidelines for the diagnosis and treatment of unstable angina endorsed

by the ACC and the AHA stratify risk assessment as being low, moderate,
or high based on patient history, physical examination findings, and
initial resting ECG tracings.
In low-risk patients with unstable angina who are evaluated in an
outpatient setting, exercise or pharmacological stress testing should
generally be performed within 72 hours of presentation. In low- or
intermediate-risk patients with unstable angina who have been
hospitalized for evaluation, exercise or pharmacological stress testing
should generally be performed unless cardiac catheterization is indicated.
Testing can be performed when patients have been free of active ischemic
or heart failure symptoms for a minimum of 8-12 hours. Intermediate-risk
patients can be tested after 2-3 days, but selected patients can be
evaluated earlier as part of a carefully constructed chest pain
management protocol (see Chest pain centers). In general, as with
patients with stable angina, the treadmill test should be the standard stress
test for patients with normal resting ECG tracings who are not taking
digoxin.
Most patients with unstable angina have an underlying ruptured plaque
and significant CAD. Some have a ruptured plaque without significant
lesions in any coronary segment as determined by angiography. Still
others have no evidence of a ruptured plaque or atherosclerotic coronary
lesions. Very little evidence exists with which to define the safety of early
exercise testing in unstable angina. One review of this area found 3
studies covering 632 patients with stabilized unstable angina who had a
0.5% mortality or myocardial infarction rate within 24 hours of their
exercise test. In addition, many available studies contain both patients
with unstable angina and those who have experienced myocardial
infarction.
The limited evidence available supports the use of exercise testing in
patients with acute chest syndrome (ACS) who have appropriate
indications as soon as they are stabilized clinically. Larsson and
colleagues compared a symptom-limited predischarge (3-7 d) exercise
test with a test performed at 1 month in 189 patients with unstable angina
or nonQ-wave infarction. The prognostic value of the two tests was
similar, but the earlier test identified additional patients who would

experience events during the period before the 1-month exercise test. In this
population, these earlier events represented one half of all events that occurred
during the first year.
The Research on Instability in Coronary Artery Disease (RISC) study group
examined the use of predischarge symptom-limited bicycle exercise testing in
740 men admitted with unstable angina (51%) or nonQ-wave myocardial
infarction (49%). The major independent predictors of 1-year infarction-free
survival in multivariable regression analysis were the number of leads with
ischemic ST-segment depression and the peak exercise workload achieved.
In 766 patients with unstable angina enrolled in the Fragmin During Instability
in Coronary Artery Disease (FRISC) study between 1992 and 1994 who had
both a troponin T level and a predischarge exercise test, the combination of a
positive troponin T level and exercise-induced ST depression stratified patients
into groups with a risk of death or myocardial infarction that ranged from 120%. In 395 women enrolled in FRISC I with stabilized unstable angina who
underwent a symptom-limited stress test at days 5-8, risk for cardiac events in
the next 6 months could be stratified from 1-19%. Important exercise variables
included not only ischemic parameters such as ST depression and chest pain
but also parameters that reflected cardiac workload.[8]

Patients without high-risk markers based on this evaluation (78%)

underwent a symptom-limited Bruce exercise ECG test. No adverse
events were reported from the testing, and the authors estimated a 5%
prevalence of CAD in the tested population. These results are generally
representative of the results in the approximately 2100 patients with chest
pain who have undergone exercise testing as part of a chest pain center
protocol report. The prevalence of CAD is extremely low in such
patients, and the risk of adverse events with testing is correspondingly
low.[10]
Farkouh and colleagues from the Mayo Clinic examined the use of
exercise testing in 424 intermediate-risk patients with unstable angina (as
defined by the ACC/AHA Committee to Develop Guidelines for the
Management of Patients With Unstable Angina) as part of a randomized
trial of admission to a chest pain unit versus standard hospital admission.
Event rates (death, myocardial infarction, congestive heart failure) did
not significantly differ among the 212 patients in the hospital admission
group and the 212 patients in the chest pain unit group. Of the total chest
pain unit group, 60 patients met the criteria for hospitalization before
stress testing, 55 had an indeterminate or high-risk test result, and 97 had
negative stress test findings. No complications were directly attributable
to the performance of a stress test in these patients.[11]

Chest pain centers[9]

Over the last decade, increasing experience has been gained with the use of
exercise testing in emergency department chest pain centers. The goal of a
chest pain center is to provide rapid and efficient risk stratification and
treatment for patients with chest pain who are believed to possibly have acute
coronary disease. Various physical and administrative setups have been used
for chest pain centers in medical centers across the country; review of these
details is beyond the scope of these guidelines. In most of the published series,
exercise testing has been reserved for the investigation of patients who are lowrisk based on history and physical examination, 12-lead ECG, and serum
markers.
In the study by Gibler et al, 1010 patients were evaluated with clinical
examination, 9 hours of continuous ST monitoring, serial 12-lead ECGs, serial
measurement of creatine kinase-MB levels, and resting echocardiograms.

These results demonstrate that exercise testing is safe in low-risk patients

with chest pain who present to the emergency department. In addition,
testing appears safe in carefully selected intermediate-risk patients. Use
of early exercise testing in emergency department chest pain centers
improves the efficiency of treatment in these patients (and may lower
costs) without compromising safety. However, exercise testing in this
setting should be performed only as part of a carefully constructed
management protocol and only after the patients have been screened for
high-risk features or other indicators for hospital admission.

Exercise testing after myocardial infarction

Importantly, when considering exercise stress testing after myocardial
infarction, consider the appropriate time frame with regard to risks and

benefits of the test before it is performed. The AHA/ACC guidelines outlining

this stratification are as follows:
o

Class I
Before discharge for prognostic assessment, activity
prescription, or evaluation of medical therapy (submaximal at
approximately 4-7 d): Exceptions are noted under classes IIb
and III.
o Early after discharge for prognostic assessment, activity
prescription, evaluation of medical therapy, and cardiac
rehabilitation if the predischarge exercise test was not performed
(symptom-limited at approximately 14-21 d): Exceptions are
noted under classes IIb and III.
o Late after discharge for prognostic assessment, activity
prescription, evaluation of medical therapy, and cardiac
rehabilitation if the early exercise test was submaximal
(symptom-limited at approximately 3-6 wk): Exceptions are
noted under classes IIb and III.
Class IIa - After discharge for activity counseling and/or exercise
training as part of cardiac rehabilitation in patients who have undergone
coronary revascularization
Class IIb
o Before discharge in patients who have undergone cardiac
catheterization to identify ischemia in the distribution of a
coronary lesion of borderline severity
o Patients with the following ECG abnormalities: complete left
bundle branch block, preexcitation syndrome, LVH, digoxin
therapy, greater than 1 mm of resting ST-segment depression,
and electronically paced ventricular rhythm
o Periodic monitoring in patients who continue to participate in
exercise training or cardiac rehabilitation
Class III
o In cases of patients with severe comorbidity likely to limit life
expectancy, candidacy for revascularization, or both
o At any time, to evaluate patients with acute myocardial
infarction who have uncompensated congestive heart failure,
o

cardiac arrhythmia, or noncardiac conditions that severely

limit their ability to exercise (level of evidence: C)
Before discharge, to evaluate patients who have already
been selected for, or have undergone, cardiac
catheterization (Although a stress test may be useful
before or after catheterization to evaluate or identify
ischemia in the distribution of a coronary lesion of
borderline severity, stress imaging tests are recommended
[level of evidence: C].)

Current guidelines for the treatment of patients with acute myocardial

infarction include medical therapy, thrombolytic agents, and coronary
revascularization. These interventions have led to a marked improvement
in prognosis for postinfarction patients, particularly those who have been
treated with reperfusion, and mortality rates are low among patients who
have received thrombolytic agents or direct angioplasty. Patients who are
unable to perform an exercise test have a much higher rate of adverse
events than those who are able to perform an exercise test. Symptomatic
ischemic ST depression with exercise testing after thrombolytic therapy
increases the risk of cardiac mortality 2-fold, but the absolute risk rate
remains low (1.7% at 6 mo).
Exercise testing after myocardial infarction is generally safe.
Submaximal testing can be performed at 4-7 days, and a symptomlimited test can be performed 3-6 weeks later. Some experts feel that
symptom-limited tests can be conducted early after discharge, at
approximately 14-21 days.
Exercise testing is useful in activity counseling after discharge from the
hospital, and it is also an important tool in exercise training, as part of
comprehensive cardiac rehabilitation for assessing the patient's response
to the exercise training program.

Cardiopulmonary exercise testing

Cardiopulmonary exercise testing (CPET) combines exercise testing with

ventilation gas analysis, and the recommendations according to the ACC/AHA
guidelines are as follows:

Class I
For evaluation of exercise capacity and response to therapy in
patients with heart failure who are being considered for heart
transplantation
o Assistance in differentiating cardiac versus pulmonary
limitations as a cause of exercise-induced dyspnea or impaired
exercise capacity when the cause is uncertain
Class IIa - Evaluation of exercise capacity when indicated for medical
reasons in patients with unreliable estimates of exercise capacity from
exercise test time or work rate
Class IIb
o Evaluation of the patient's response to specific therapeutic
interventions in which improvement of exercise tolerance is an
important goal or end point
o Determination of the intensity for exercise training as part of
comprehensive cardiac rehabilitation
Class III - Routine use to evaluate exercise capacity
o

CPET is a useful adjunctive tool for the assessment of patients with

cardiovascular and pulmonary disease and involves measurements of gas
exchange, which primarily include oxygen uptake (ie, VO2), carbon dioxide
output (VCO2), minute ventilation, and anaerobic (lactic acid) threshold.
Patients usually wear a nose clip and breathe through a nonrebreathing valve
that separates expired air from room air. VO2 at maximal exercise (peak VO2) is
considered the best index of aerobic capacity and cardiorespiratory function.
Estimation of maximal aerobic capacity using published formulas based on
exercise time or work rate without direct measurement is limited by
physiological and methodological inaccuracies.
According to current data acquired from patients with heart failure undergoing
cardiopulmonary stress testing using this method, subsequent analysis has been
demonstrated to be reliable and important, and subsequent analysis benefits this
subgroup of patients the most. Such data are only partly influenced by resting

left ventricular dysfunction. Maximal exercise capacity does not

necessarily reflect the daily activities of patients with heart failure. Use of
this technique in stratification of patients with ambulatory heart failure
has improved the clinician's ability to identify those with the poorest
prognosis who should be considered for heart transplantation.
Abnormal ventilatory and chronotropic responses to exercise are also
predictors of outcome in patients with heart failure.[12] In addition,
evaluation of the rate of VO2 decline during exercise recovery (VO2
kinetics) may provide additional information regarding the functional
state in patients with heart failure. Compared with normal oxygen
kinetics, prolonged recovery time of VO2 has been correlated with poorer
exercise tolerance, lower peak VO2, and a lower cardiac index. Most
investigators conclude that measurement of peak VO2 yields the best
prognostic information in patients with heart failure. Evaluation of
submaximal and recovery ventilatory responses may be particularly
useful when exercise to near-maximal levels (respiratory exchange ratio
greater than 1) is not achieved.

Special groups: Female, asymptomatic, and

postrevascularization patients
Diagnosis of CAD in female patients
The usefulness of exercise ECG for the diagnosis of coronary disease in
women has limitations. Exercise-induced ST depression is less sensitive
in women than men, reflecting a lower prevalence of severe coronary
disease and the inability of many women to exercise to maximum aerobic
capacity. Exercise ECG findings are also commonly viewed as less
specific in women than in men, although careful review of the published
data demonstrates that this finding certainly has not been uniform.
Studies that demonstrated lower specificity in women have cited lower
disease prevalence, non-Bayesian factors, and possible hormonal
differences. It is important to be cognizant of the decrease in sensitivity
that occurs when women do not exercise to maximum aerobic capacity.
Patients likely to exercise submaximally should be considered for

pharmacological stress testing. Concern about false-positive ST-segment

responses may be addressed by careful assessment of posttest probability and
selective use of stress imaging tests before proceeding to angiography.

Although the optimal strategy for circumventing false-positive test results for
the diagnosis of CAD in women remains to be defined, data are insufficient to
justify routine stress imaging tests as the initial test for the diagnosis of CAD in
women.
Diagnosis of CAD in elderly patients
CAD is highly prevalent in symptomatic elderly patients (older than 65 y).
Pharmacological stress testing is required more often in elderly patients
because of their inability to exercise adequately.
Interpretation of exercise test results from elderly patients differs somewhat
from that in younger patients. Resting ECG abnormalities may compromise the
accuracy of diagnostic data from the ECG. Nonetheless, the application of
standard ST-segment response criteria to elderly subjects does not appear to be
associated with a significant difference in accuracy from that of younger
patients. Due to the greater prevalence of severe CAD, exercise testing in this
group is reported to have a slightly higher sensitivity than in younger patients.
A slightly lower specificity has also been reported, which may reflect the
coexistence of LVH due to valvular disease and hypertension. Although the risk
of coronary angiography may be greater in elderly patients and the justification
for coronary intervention less, the results of exercise testing in elderly patients
remain important because medical therapy may carry substantial risks for this
group.
Exercise testing in asymptomatic persons without known CAD
According to the ACC/AHA classification that follows, no indications exist for
routine exercise testing in asymptomatic persons without known CAD or risk
factors.

Class I - None
Class IIa - Evaluation of asymptomatic persons with diabetes mellitus
who plan to start vigorous exercise (level of evidence: C)

Class IIb
o Evaluation of persons with multiple risk factors (as a
guide to risk-reduction therapy): Multiple risk factors are
defined as hypercholesterolemia (cholesterol more than
240 mg/dL), hypertension (SBP greater than 140 mm Hg
or DBP greater than 90 mm Hg), smoking, diabetes, and
family history of heart attack or sudden cardiac death in a
first-degree relative younger than 60 years. An alternative
approach might be to select patients with a Framingham
risk score consistent with at least a moderate risk of
serious cardiac events within 5 years.
o Evaluation of asymptomatic men older than 45 years and
women older than 55 years, including those who plan to
begin vigorous exercise (especially if previously
sedentary), those who are involved in occupations in
which impairment might impact public safety, and those
who are at high risk for CAD due to other diseases (eg,
chronic renal failure and peripheral vascular disease)
Class III - Routine screening of asymptomatic men or women

The goal of screening for possible CAD in asymptomatic patients is to

either prolong life or improve quality of life. This has been supported by
data from the Coronary Artery Surgery Study and the ACIP study in
asymptomatic patients with severe CAD, which suggests that performing
revascularization may prolong life.
Although current clinical guidelines suggest risk reduction factors in all
people, the detection of ischemia after stress testing results indicate
functional impairment may further motivate patients to be more
compliant with a program of risk factor modification.
Prediction of myocardial infarction and death are considered the most
important end points of screening asymptomatic patients. In general, the
relative risk of a subsequent event is increased in patients with a positive
exercise test result, although the absolute risk of a cardiac event in an
asymptomatic patient remains low. The annual rate of myocardial
infarction and death in such patients is approximately 1%, even when STsegment changes are associated with risk factors. A positive exercise test

result is more predictive of later development of angina than the occurrence of

a major event. Even when subsequent angina is considered an event, a minority
of patients with a positive test result experience cardiac events. Unfortunately,
patients with positive test results may be labeled at risk.
For example, general population screening programs attempting to identify
young patients with early disease are limited in that severe CAD requiring
intervention in asymptomatic patients is exceedingly rare. Although the
physical risks of exercise testing are negligible, false-positive test results may
(1) engender inappropriate anxiety, (2) have serious adverse consequences
related to work and insurance coverage, and (3) lead to complications from
further diagnostic testing. For these reasons, exercise testing in healthy,
asymptomatic persons is not recommended.
Selected patients with multiple risk factors for CAD are at greater absolute risk
for subsequent myocardial infarction and death. Screening may potentially be
helpful in patients who are at moderate risk, as defined by the available
prognostic data from asymptomatic persons in the Framingham study. For these
purposes, define risk factors very strictly. Multiple risk factors are defined as
hypercholesterolemia (cholesterol greater than 240 mg/dL), hypertension (SBP
greater than 140 mm Hg or DBP greater than 90 mm Hg), smoking, diabetes,
and family history of heart attack or sudden cardiac death in a first-degree
relative younger than 60 years. An alternative approach might be to select
patients with a Framingham risk score consistent with at least a moderate risk
of serious cardiac events within 5 years. Attempts to extend screening to
persons with lower degrees of risk are not recommended because screening is
extremely unlikely to improve patient outcome.
A study of 6578 asymptomatic individuals who performed Bruce treadmill tests
were observed for 20 years to assess the risk of cardiovascular death. Weiss et
al determined that elevated exercise blood pressure in asymptomatic
individuals had a higher risk of cardiovascular death, but the risk become
nonsignificant after accounting for rest blood pressure. Bruce stage 2 blood
pressure 180/90 mm Hg identified those without hypertension at high risk of
cardiovascular death.[13] Good blood pressure control in individuals with
asymptomatic hypertension is always desirable for overall long-term good
prognosis.

Valvular heart disease

According to the ACC/AHA guidelines, no recommendations exist for
routine exercise testing of patients with valvular heart disease. The
current recommendations for which patients with valvular heart disease
should undergo exercise testing are as follows:

Class I - None
Class IIb - Evaluation of exercise capacity of patients with
valvular heart disease: The presence of symptomatic, severe aortic
stenosis is a contraindication to exercise testing.
Class III - Diagnosis of CAD in patients with valvular heart
disease

In symptomatic patients with documented valvular disease, the course of

treatment is usually clear, and exercise testing is not required. Further, the
expanding use of Doppler echocardiography has greatly increased the
number of asymptomatic patients with well-defined valvular
abnormalities, the etiology of which may be other than ischemic (ie,
congenital abnormalities).
The primary value of exercise testing in persons with valvular heart
disease is to assess atypical symptoms, exercise capacity, and the extent
of disability objectivelyall of which may have implications for clinical
decision making. Assessment is particularly important in elderly patients,
who may not have symptoms because of limited activity. Use of the
exercise ECG for diagnosis of CAD in these situations is limited by falsepositive responses due to LVH and baseline ECG changes.
In patients with aortic stenosis, a clinician familiar with the patient's
condition should supervise the test directly, and exercise should be
terminated for inappropriate blood pressure augmentation, slowing of the
heart rate with increasing exercise, or premature beats.
Because the major indication for surgery in mitral stenosis is symptom
status, exercise testing is most valuable when a patient is thought to be
asymptomatic due to inactivity or when a discrepancy exists between the
patient's symptoms and the valve area. Because ejection fraction is a

reliable index of left ventricular function in aortic regurgitation, decisions

regarding surgery are likely to be based on resting ejection fraction values, and
exercise testing is not commonly required unless symptoms are ambiguous.
Resting ejection fraction is a poor guide to ventricular function in patients with
mitral regurgitation; thus, combinations of exercise and assessment of left
ventricular function may be of value in documenting occult dysfunction.
Exercise testing before and after revascularization
Exercise testing in patients after revascularization constitutes an important part
of treatment of these patients because the risk of undergoing major surgery
the risks versus benefitsmust be considered carefully and the patients must
be assessed properly. The current ACC/AHA guidelines are as follows:

Class I
Demonstration of proof of ischemia before revascularization
Evaluation of patients with recurrent symptoms suggesting
ischemia after revascularization
Class IIa - After discharge for activity counseling and/or exercise
training as part of cardiac rehabilitation in patients who have undergone
coronary revascularization
Class IIb
o Detection of restenosis in selected, high-risk, asymptomatic
patients within the first months after angioplasty
o Periodic monitoring of selected, high-risk, asymptomatic
patients for restenosis, graft occlusion, or disease progression
Class III
o Localization of ischemia for determining the site of intervention
o Routine, periodic monitoring of asymptomatic patients after
PTCA or CABG without specific indications
o
o

Current AUC guidelines do not recommend routine testing within 2 years for
patients who have undergone coronary revascularization procedures. However,
one study has shown that 12% of these patients who visit their physician at
least 3 months after the procedure undergo stress testing within 30 days of the
visit. The study shows discretionary stress testing is performed more frequently
by physicians who bill for technical and professional fees compared to

physicians who do not bill for these services, possibly as a way to recoup
upfront costs for imaging equipment.[14]
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